Professional Documents
Culture Documents
DSM Iv TR
DSM Iv TR
TEXT REVISION
,
Published by the American Psychiatric Association Washington, DC
Copyright 2000 American Psychiatric Association DSM, DSM-JV, and DSM-IV-TR are trademarks of the American Psychiatric Association. Use of these terms is prohibited without permission of the American Psychiatric Association. ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be reproduced or used in a manner inconsistent with the AP A's copyright. This prohibition applies to unauthorized uses or reprod\lctions in any form, including electronic .1 pplications. Correspondence regarding copyright permissions should be directed to the DSM Permissions, Office of Publishing Operations, American Psychiatric Association, 1400 K Street, N.W., Washing ton, DC 20005. Manufactured in the United States of America on acid-free paper. American Psychiatric Association }.l{lO K Street, N W., Washington, DC 20005 www.psych.org The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical MaJlJlal of Mf'Jl ta/ Disorders, Fourth Edition, Text Re,rision . Washington, DC, American Psychiatric Association, 2()()() . library of Congress Cataloging-in-Pub lication Data Diagnostic .md sta tis tical manual of mental d isorders: OS},,I-IV . -Ith ed . , text revision . p. ; cm. Prepared by the Task Force on DSM-IV and othercommittecs and workgroups of the American PsychiatriCAssociation . Includes index . ISBN Q...S9O-U.-024-6 (casebound: alk . paper)-ISBN 0-890-12-025-4 (pbk..: alk . paper) 1. t-,'Ienlal illness Classification-Handbooks, manuals, etc . 2. Mental ilIness-DiagnosisHandbooks, man uals, etc. I.. Tille: OSM-IV. II.. American Psychiatric Association . Ill. American Psychiatric Association . Task Force on OSM-IV . [DNLM: 1. Mental Oisorders--classification . 2. Mental Disorders--diagnosis. WM 15 0536 2000J RC455 . 2. CI. 0536 2000 616. S9'075-d.c21
00-02-1852
British library Cataloguing in Pu b li cation Data A crr record is available from the British Library . Text Design- Anne Barnes Manufacturing-R.. R.. Donnelley & Sons Comp.m y
Contents
Task Force on DSM-IV .... ..... . . .. ... .......... . . .. .... xi W o rk Groups for the DSM-I V-TR Text Revision ............... xv Acknow ledgments f or DSM-IV-TR .. ............. . . . .... xix Acknow ledgments for DSM-IV Text Revision ..... ... . .. . .. .. . ............ xxi . ... Intro d uctlon ......... . ....... .. ..................... XX III
Other Cognitive Disorders . .... . . . . . ..................... 135 Mental Disorders Due to a General Med ical Condition .. .. .... 181 Substan ce-Related Disorders ...... ........ . ....... .... . . . 191 Schizoph renia and Other Psychoti c Di sorders . ..... .. ... . ............. . ..... 297
Mood Di sorders . .. .... .... .. . . . . . . . . . . . . . . . . . . . .. ... . . 345
Eating Disorders ...... ................ . . . . . . . ... 583 Sleep Disorders ... .............. ....................... 597 Impulse-Control Disorders Not Elsewhere Classified .... . . .... 663 Adjustment Disorders .................................. 679 Personality Disorders .............. . . . . . . ....... . .... 685 Other Conditions That May Be a Focu s of Clinical Attention ........ .. . . ... ... . .... . .. 731 Additional Codes ...... ................ ..... . . . . ..... 743
Appendix A
Decision Trees for Differential Diagnosis . ................. . 745
Appendix B Criteria Sets and Axes Provided for Further Study .......... . 759 Appendix C Glossary of Techni ca l Terms ....... ................... 819 Appendix D Highlights of Changes in DSM-IV Text Revision ............... .. ... ........ 829 Appendix E Alphabetical Listing of DSM-IV-TR Diagnoses and Codes ..................... 845 Appendix F
Numerical Listing of DSM-IV-TR Diagnoses and Codes ............. . . . . ... 857
Appendix H DSM-IV Classification (W ith ICD-1O Codes) ..... ... ....... ... .. ..... 883 Appendix I Outline for Cultural Fo rmul ati o n and Glossary of Culture-Bound Syndromes ........ . .. . . ... .. 897 Appendix J DSM -IV Co nt rib ut o rs .... ... . . ..... . . . . ........... 905 Appendix K DSM-I V Text Revisio n Advi sers . . .. .... . ................... 929
C/zairpersoll
H AROLD AL AN PlNCUS, M .D .
\'ice-Clw irpersoll
David
J. Kupfer, M.D.
Jolm C. Urbaitis, M.D. Assembly Liaisoll James J. Hudziak, M.D. Residell t Fellow (1990---1993)
XII
DSM-IV Wo rk Groups
Delirium, Dementia, and Amnestic and Other Cognitive Disorders Work Group
Gary 1. Tucker, M.D. Marshall Folslem, M.D.
Gary Lloyd Gottlieb, M.D.
Chairperson
Michael Popkin, M.D.
ViceC/mirpersoll
Eric Douglas Caine, M .D.
Disorders Usually First Diagnosed During Infancy, Childho od, or Ad olescen ce Wo rk Group
David Shaffer, M. D. Co-Chairperson
r-,'Iagda Campbell, M.D.
Co-Clmirpersoll
Susan J. Bradley, M.D.
XIII
Psychiatric Systems Interface Disorders (Adjustment, Di ssociative, Fa ctitious, Impulse-Control, and Somatoform Disorders and Psycho logica l Factors Affecti ng Medical Conditions) Wo rk Group
Robert E. Hales, M .D. Clw;rpersoll
C. Robert Cloninger, M.D.
Steven A. King, M D. Ronald L. Martin , M.D. Katharine Anne Phillips, M. D. David A. Spiegel, M.D. Alan Stoudem ire, M .D. James J. Strain, M.D. Michael G. Wise, M .D.
V ice-Clwi rpersoll
Jonathan F. Borus, M.D. Jack Denning Burke, Jr., M.D., M.P.H. Joe P. Fagan, M.D.
XIV
Chairperson
Cha rles F. Reynolds III, M.D. Vice-ella irpersol!
Chairpersoll
John E. Helzer, M.D. Vice-C/In;'persoll
Jer ry M. Lewis, M.D. Consultant (1 988-1994) Daniel J. Luchins, M.D. COllsultant (1 987-1991) Katharine Anne Phillips, M.D. COl/slt/tant (1992-1994) Cyn thia Pearl Rose, M.D. Consultant (1990-1994) Louis Ala n Moench, M.D. Assembly LiaiSOIi (199 1- 1994) Steven K. Dobscha, M .D. Resident Fellow (1990-1992) Mark Zinunerman, M.D. Residellt Fellow (199 2- 1994)
Kenneth Z. Altshule r, M.D. (1987-1992) Thomas F. Anders, M.D. (1988-1994) Susan Jane Blum enthal, M.D. (1 9901993) Leah Joan Dickstein, M .D. (1988-1991) Le wis J. Judd , M .D. (1988-1994) Gerald L. KIerman, M .D. (deceased) (1988-1991) Stuart C. Yud ofsky, M.D. (1992-1994) Jack D. Blaine, M .D. Consultant (1987-1992)
Joint Committee of th e Board of Tru st ees and Assembly of Dist rict Branches on Issues Related to DSM-I V
Ronald A. Shellow, M. D. ClUlirperson Harvey Bluestone, M.D. Leah Joan Dickstein, M .D. Arthur John Fa rley, M .D . Carol Ann Berns tein, M.D.
Co-Chilirpersolllllld Editor
H AROLD ALAN P INCUS, M.D. Co-C/mirpersoll
Disorde rs Usually First Diagnosed During Infancy, Childhood, or Adolescence Text Revision Work Group
David Shaffer, M.D. Clmirpersoll
Dona ld
Pine, M .D.
J. Cohen, M.D.
xv
I xvi
Mark S. Bauer, M.D. Patricia Suppes, M.D., Ph.D.
Marc Feldman, M.D. Eric Hollander, M.D. Steven A. King, M. D. James Leven son, M.D.
Ronald L Mar tin, M.D. (deceased)
Cltairpersoll
XVII
Louis Alan Moench, M.D. Assembly Liaisoll Jack Barchas, M.D. Corresponding Member Herbert '''.'. H arris, M.D., Ph .D. Correspolldillg Member Charles Kaelber, M.D. CorrespoJldillg Member Jorge A. Costa e SiJva, M.D. Correspol/dil/g Member
Member
OanieJ Wins tead , M.D. Member
Bonnie Zima, M.D., Ph.D. lvIcmber Barbara Kenned y, M.D., Ph .D. COl/sultant Janet B. W. W illiams, OS .W . COl/sultaJlt
SM-TV was a team effort. More than 1,000 people (and numerou s professional organiza tions) have helped us in the preparation of this docum ent. Members of the Task Force on DSM-IV and DSM -IV Staff are listed on p. xi, members of the DSM-IV Work Groups are lis ted on pp. xii-xiv, and a lis t of other participants is included in App endix J. The major responsibility for the content of DSM-I V rests with the Task Force on DSM-IV and members of the DSM-lV Work Groups. They have worked (often much harder than they bargained for) with a dedication and good cheer that has been inspirational to us. Bob Spitzer has our special thanks for his untiring efforts and unique perspective. Norman Sartorius, Darrel Regier, Lewis Ju dd, Fred Goodwin, and Chuck Kaelber were instrumental in facilitating a m utually productive interchange between the American Psychiatric Association and the World Health O rganization that has improved both DSM-IV and ICD-lO, and increased their compatibility. We are grateful to Robert Israel, Sue Meads, and Amy Blum at the National Center for Health Statistics and Andrea Albawn-Feinstein at the American Health Information Management Association for suggestions on the DSM-IV coding system . Denis Prager, Peter Na than, and David Kupfer helped us to develop a novel data reanal ysis strategy that has been supported with fundin g from the John D. and Ca therine T. MacA rthur Fowldation. Many individuals w ithin the American Psychiatric Association deserve recognition. Mel Sabshin's special wisdom and grace made even the most tedious tasks seem worth doing. The American Psychiatric Association Committee on Psychiatric Diagnosis and Assessment (chaired by Layton McCurdy) provided valuable direction and counsel . We would also like to thank the American Psychiatric Association Presidents (Drs. Fink, Pa rdes, Benedek, Hartmatm, Eng lish, and Mcintyre) and Assembly Speakers (Drs. Cohen, FlatIUTI, Hanin, Pfaehler, and Shellow}.\vho helped wi th the planning of our work. Carolyn Ra binowitz and Jack White, and their respective staffs in the American Psychiatric Associa tion Medica l Director's Offi ce and the Bus iness Admi.nistration Office, have provided valua ble assis tatlCe in the organization of the project. Several other individu als have our special gra ti tude. Wendy Davis, Nancy Vettorello, and Nancy Sydnor-Greenberg developed an d implemented an organizational struchlre that has kept this com plex project from spuming out of control. We ha ve also been b lessed w ith an wlUs lially a ble administrative s taff, which has included Elisabeth Fitzhugh, Willa I-fall, Kelly McKinney, Gloria ~liel e, Helen Stayna, Sarah Tilly, lina Rosenthal, Susan Mann, Joanne Mas, and, esp ecially, Cind y Jones. Ruth Ross, our tireless Science Editor, has been responsible for imp roving the clarity of expression and o rganization of DSM-IV. Myriam Kline (Research Coordinator for the NIH-funded DSM-IV Focu sed Field Tria ls), Jim Thompson {Research Coordinator for
XIX
Ixx
duction assis tance.
the MacArthur Founda tion-funded Videotape Field Trial), and Sandy Ferris (Assistant Director for the Office of Research) have made many val uable contributions. We would also like to acknowledge all the other staff persons at the American PsychialTic Association who have helped w ith th is project. Ron McMiUen, Claire Reinburg, Pam
Harley, and Jane D.1Venport of American Psychiatric Press have provided expert pro-
T he effort to revise the DSM-IV text WilS also a team effort. We are especially indebted to the tireless efforts of the DSM-IY Text Revision Work Groups (listed on pp. xv- xvii), w ho did the lion's share of the work in the preparation of this revision. ' Ne would also llke to acknowledge the contribution of the various .1dvisers to the Work Groups (see Appendix K, p . 929), w ho provided their p erspccti\!C on whether the proposed dlanges were jus tified . Fina lly, we would like to tha nk the American Psychiatric Association's Committee on Psychiatric Diagnosis and Assessment (listed on p. xvii), w ho provided helpful guidance and oversigh t during the p rocess as well as approv,, ! of the final d ocument. Special g ratitude goes to committee members Katharine A. Phillips and Janet B. W. \o\' i11ial11s, for their meticulous ly careful review of the text revision. O f course, none of this could have happened without the invaluable organizational and administrative assistance provided by the DSM-IV s taff, Laurie tvlcQueen and Yoshie Satake, and production assis tance provided by Anne Barnes, Pam Harley, Greg Kuny, Claire Rcinburg, and Ron McMillen at American Psychiatric Press. First, MD. Co-ChnirpersOIl nnd Editor Harold AJan Pi.ncus, M.D. Co-Clltlirl'crson
~'lichae l l3.
XXI
Introduction
is the fourth edition of the American Psychiatric Association's Diagnostic alld Statistical Mml/wl of Melltal Disorders, or DSM-IV. The utility and credibility of DSM-IV requ ire that it fOCllS on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped 10 make DSM-IV practical and useful fo r clinicians by striving fo r brev ity of criteria sets, clarity of language, and explicit statements of the constructs embodied in Ule diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers. We were also mindfu l of the usc of DSM-IV for improving the coUeetian of clinical information and as an educational tool for teaching psychopathology. An offi cial nomenclature mus t be applicable in a wide diversit}' of contex ts. DSM-IV is used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, famil y / systems). It is used by psychiatrists, other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, counselors, and other h ealth and mental health professionals. OSM-JV must be usable across settings- inpatient, outpatient, partial hospital, con sultation-liaison, clinic, private practice, and primary care, and w ith community popu lations. It is also a necessary tool for collecting and commwucating accurate public health s tatistics. Fortunately, all these many llses are compatible with one another. OSM-JV was the product of 13 Work Groups (see Appendix]), each of which had primary responsibility fo r a section of the manual. This organiza tion was designed to increase participation by experts in each of the respective field s. We took a number of precautions to ens ure that the Work Group recommendations would reflect the breadth of available evidence and opinion and not jus t the v iews of the specific members. After extensive consu Itations wi th experts and c1ihicians in each fie ld , we selected ''''ark Group members who represented a wide range of perspectives and experiences. Work Group members w ere instructed that they were to participate as consens us scholars and not as advocates of previously held views. Furthermore, we established a formal evidence-based process for the Work Groups to foll ow. The Work Groups reported to the Task Force on DSM-JV (see p. xi), which consis ted of 27 members, many of whom also chaired a Work Group. Each of the 13 Work Groups was composed of 5 (or more) members whose reviews were critiqued by between SO and 100 advisers, who were also dlOsen to represent diverse clinical and research expertise, disciplines, backgrounds, and settings. The involvement of many international experts ensured that DSM-rv had available the wides t pool of information and would be applicable across cu ltures. Conferences and workshops were held to provide conceptual and methodological guidance for the DSM-IV effort. These
XXIII
ThiS
XXIV
Introduction
included a number of consultations between the developers of DSM-IV and the developers of lCD-tO conducted for the purpose of increasing compatibility between the two systems . Also held were m ethods conferences tha i focused on cultural fa ctors in the diagnosis of mental disorder, on geriatric diagnosis, and on psychiatric diag-
Historical Background
The need fo r a classification of mental disorders has been clear throughou t the history o f medicine, but there has been little agreement on which d isorders should be indud cd and the optimal method for thei r organization. The many nomenclatures that have been developed during the past two millermia have diffe red in their rela tive emphasis on phenomenology, etiology, and course as d efining features. Some systems have included only a handful of diagnostic categories; others have included thousands. Moreover, the variou s systems for categorizing mental d isorders have differed with respect to whether their p rinciple objective was for use in clinica l, research, or s l a ti s~ tica l settings. Because the history of classification is too extensive to be summarized
Introduction
xxix
fourth volume contains reports of the data reanalyses, reports of the field trials, and a final executive swnmary of the rationale fo r the decisions made by each Work Group. In addi tion, many papers were s timulated by the efforts toward empirical documentation in DSM-IV, and these have been published in peer-reviewed journals.
Relation t o ICD-1 0
The tenth revision of the International Statistical Classificalioll of Diseases aud Related H eaftll Problems (JCD- lO), developed by WHO, was published in 1992. A clinical modification of lCD-to (lCD-In-eM) is expected to be implemented in the United States in 2004. TIlOse preparing ICDlO and DSM-JV have worked closely to coordinate their efforts, resulting in much mutua l influence. ICD-IO consists of an official coding system and o ther rela ted clinica l and research d ocuments and instruments. The codes and terms provided in DSM-IV are full y compatible w ith both ICD-9-CM and ICD-lO (see Appendix H). The clinical and research drafts of ICD-10 were thoroughly reviewed b}' the OSM-JV Work Groups and suggested important topics for DSM-IV literature reviews and data reanalyses. Draft versions of the ICD-lO Diagnostic Criteria for Research were included as alternati ves to be compared with DSM-fIl, OSM-ill-R, and s uggested OSM-lV criteria sets in the DSM-lV field trials. The many consultations between the developers of OS~'I- lV and lC D-10 (which were fac ilitated by N IMH, i\TJDA, and N IAAA) were enormously useful in increasing the congruence and reducing meaningless differences in wording between the two systems.
Introductio n
xxv
here, we focus briefly on ly on those aspects that have led directly to the development of the Diagnostic and Statistical Manllal of Mentnl Disorders (DSM) and to the "Mental Disorders" sections in the various editions of the Illternatiollal Classification ofDisenses
(!CD ).
In the United States, the initial impetus for developing a classification of mental disorders was the need to collect statis tical information. What might be considered the first official attempt to gather information about menial illness in the United States was the recording of the frequ ency of one category-"idiocy / insanity" in the 1840 census. By the 1880 census, seven categories of mental illness were distinguished-mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, the Committee on Statistics of the American Psychiatric Association (a t that time called the American Medico-Psychological Association (the name was changed in 1921)), together with the National Commission on Mental Hygiene, formulated a plan that was adopted by the Bureau of the Census for ga thering uniform statistics across mental hospitals. Although th is system devoted more attention to clinical utility than did previous systems, it was still primarily a statistical classification. TIle American Psychiatric Association su bsequently collaborated with the New York Academy of Medicine to develop a nationally acceptable psychiatric nomenclature that wou ld be incorporated w ithin the first edition of the American Medic,lJ Association's Standa rd Classified Nomenclahue of Disease. This nomenclature was designed primarily for diagnosing inpatients with severe psychiatric and neurological disorders. A much broader nomenclature was later developed by the US. Army (and modified by tile Veterans Adminis tration) in order to better incorporate the outpatient presentations of World War II servicemen and veterans (e.g., psychophysiological, personality, and acute disorders) . Con temporaneously, the World Health Organization (W HO) published the sixth edition of lCD, which, for the first time, included a section for mental disorders. rCD-6 was heavily influenced by the Veterans Administration nomenclature and included 10 categories for p sychoses, 9 for psychoneuroses, and 7 for disorders of character, behavior, and intelligence. The American Psychiatric Association Committee on Nomenclature and Statistics developed a variant of the ICD-6 that was published in 1952 as the first edition of the Diagnostic alld Statistienl Mallllfll: Melltal Disorders (DSM-I). DSM-I contained a g lossary of descriptions of the diagnostic ca tegories and ,,:-as 'the first official manual of mental disorders to focu s on clinical util ity. TIle lise of the term reactioll throughout DSM-I reflected the influence of Adolf Meyer's psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors. In part because of the lack of widespread acceptance of the mental disorder taxonomy contained in ICD-6 and ICD-7, WHO sponsored a comprehensive review of diagnostic issu es that was conducted by the British psychiatrist Stengel. His report can be credited with having inspired many of the recent advances in diagnostic methodology-most especially the need for explicit definitions as a means of promoting reliable clinical diagnoses. However, the next round of diagnostic revision, which led to DSM-ll and lCD-8, did not follow Stengel's recommendations to any great degree. DSM-ll was similar to DSM-I but elimi.nated the term reactioll. As had been the case for DSM-J and DSM-II, the development of DSM-lII was co-
XXVI
Introduction
ordinated with the development of the next (ninth) version of lCD, which was pub lished in 1975 and implemented in 1978. Work began on OSM-m in 1974, with
publication in 1980. DSM-rTI introduced a number of important methodological innovations, including explicit diagnos tic criteria, a multiaxial sys tem, and a descriptive
approach that atlempted to be neutral with respect to theories of etiology. This effort
was facilitated by the extensive empirical w ork then under way an the cons truction and validation of explicit diagnostic criteria and the development o f semis tructured interv iews. ICO-9 did not include diagnostic criteria or a multiaxial system largely
becau se the primary fun ction of this international system was to delineate categories to fa cili tate the collection of basic health statistics. In contrast, DSM-lTI was developed with the additional goal of providing a medical nomenclature for clinicians and resea rchers. Because o f disSatisfaction across all of medicine with the lack of specificity in lCD-9, a decision was made to modify it for use in the United States, resulting in ICD-9-CM (for Clinical Modification). Experience with DSM-lll revealed a number of inconsistencies in the system and a number of instances in which the cri teria were not entirely clear. Therefore, the American Psychiatric Assoda tion appo inted a Work Group to Revise DSM-lll, w hich developed the revisions and co rrections that led to the publication of OSM-ill-R in 1987.
Introduction
xxvii
stud ies considered, the criteria for inclusion and exclusion from the review, and the variables catalogued in each study); 3) the results of the review (including a descriptive summary of the studies with respect to methodology, design, and substantive correla tes of the find ings, the relevant findin gs, and the analyses conducted on these findings); and 4) the various options for resoh-ing the iss ue, the advantages and disadvan tages of each option, recommendations, and suggestions fo r additional research that would be needed to provide a more conclusive resolution. The goal of the DSM-IV literature reviews was to p rovide comprehensive and unbiased information and to ensure that DSr..'I-IV reflects the best available clinical and resea rch literature. For this reason, we used systematic computer searches and critical reviews d one by large groups of advisers to ensure that the literature coverage w as adequate and that the interpretation of the results was justified. l.np ut was solicited especiaUy from those persons likely to be critical of the conclusions of the review. The litera hue reviews were revised many times to produce as comprehensive and balanced a result as possible. It mus t be noted that for some issues addressed b y the DSM-IV Work Groups, particu larly those thai were more conceptua l in nature or for which there were insufficient data, a review of the empirical literatu re had limited utility. Despite these limitations, the reviews w ere helpful in d ocumenting the rationale and empirical support for decisions made by the DSM-IV Work Groups.
Data Reanalyses
Wh en a review of the literature revealed a lack of ev idence (or conflicting ev idence) for the resolution of an issue, we often made use of h,o add itional resources--data reanalyses and fiel d trials-to help in making fina l decisions. Ana lyses of relevan t Wlpublished data sets were su p ported by a grant to the American Psychia tric Association from the John D. and Catherine T. MacArthur Foundation. Most of the 40 data reanalyses perfonned for DSM-IV involved the col labora tion of several investigators at different sites. These researchers jointly subjected their data to question s posed by the Work Groups concerning the criteria included in DSM-lU-R o r criteria that might be included in DSM-IV. Da ta reanalyses aJso made it possible for Work Groups to generate several criteria sets that were then tested in the DSM-IV field trials. Although, for the most part, the data sets used in the reanalj'ses h ad been collected as part of epidemiological studies or treatmen t or other clinica l studies, they were also highly relevant to the nosological questions facing the DSM-T Work Groups. V
Field Tria ls
Twelve DSM-IV fie ld trials were s ponsored by the ational Institute of Mental Health (NIMH) in collaboration with the National lnsti tute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NlAAA). The field trials allowed the DSM-IV Work Grou ps to compare alternative optio ns and to study the possible impact of suggested changes. Field trials compared DSM-ill, OSM-ill-R, lCD-IO, and proposed DSM-IV criteria sets in 5-10 different sites per fi eld trial, with approximately 100 subjects at each site. Diverse sites, with represen tative groups of subjects hom a range of sociocultural and ethnic backgrounds, were selected to ensure generalizability of field -trial results and to test some of the most difficult ques-
XXVIII
Introduction
tions in d ifferentia l diagnosis. The 12 fi eld tria ls included more than 70 s ites and evaluated mOfe than 6,000 su bjects. The field trials collected information on the relia bili ty and perfo rmance ch a racteristics of each c riteria set as a w hole, as weUas of the sp ecific items w ithin each c riteria set. The field trials also helped to bridge the boundary beh\'een clinical research a nd clinical practice by determining how well suggestions fo r change that are derived from clinical research fi ndings apply in clinical practice.
xxx
Introduction
The chairs of the original DSMTV Work Grou ps were consw ted first regarding the composition of these Text Revision Work Groups. Each Text Revision Work Group
was given primary responsibility for updating a section of the DSM-IV text. This entailed reviewing the text carefully to identify errors or omissions and then conducting a systematic, comprehensive literature review that focused on relevant material tha t
has been publis hed since 1992. Text Revis ion Work Group members then drafted p roposed changes, which were accompanied by written justifications for the changes
along with relevant references. During a series of conference cails, the proposed
changes, justifications, and references were presented by a Text Revision Work Group member to other members of the Text Rev ision Work Group, w ho provided input regarding wheth;: the changes were justified on the basis of the supporting documentation. Once drafts of the proposed changes were finalized by the Text Rev ision Work Groups, the changes were more widely disseminated to a group of section-specific advisers (consisting of the original DSM-rv Work Group members supplemented by additiona l consultants) for fur ther comment and review. TIlese ad visers were also given the opporh.mity to suggest additional changes if they could provide sufficient convincing ev idence justifying inclusion in the text. After consideration of the adviser comments, final drafts of p roposed changes were produced and submitted for final review and approval by the American Psychiatric Association's Committee on Psychiatric Diagnosis and Assessment. Most of the proposed literature-based changes were in the Associated Features and Disorders (which includes Associa ted Laboratory Findings); Specific Culture, Age, and Gender Features; Prevalence; Course; and Fami lial Pattern sect-ions of the text. For a number of disorders, the Differential Diagnosis section also was expanded to provid e more comprehensive differentials. Appendix D (see p. 829) provides an overview of the cha nges included in this text revision.
Intro ducti on
xxxi
is a useful indicator fo r a mental disorder, but none is equivalent to the concept, and different s ituations caU for different definitions. Despite these caveats, the definition of mellial disorder that was included in DSMm and DSMW R is p rese nted here because it is as useful as any other available definition and has helped to guide decis ions regarding which conditions on the boundary between normali ty and pathology s hould be included in DSMIV. ln OSM rv, each of the mental disorders is concephlalized as a clinically significant behaviora l or p sy chological syndrome or pattern that occurs in an individual and that is associated with p resent distress (e.g., a painful symptom) or disability (i.e., impairme nt in one or more important areas of functioning) or wi th a Significantly increased risk of sui fering death, pain, disability, or an important loss of freedom . In addi tion, this syn drome or pattern must no t be me rely an expectable and culturally sa nctioned response to a particular e\'ent, for example, the death of a loved one. \hatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunc tion in the ind ividual. 'either deviant behavior (e .g., po litical, religious, or sexual) nor connicts that are primarily behveen the individual and society are mental disorders unless the deviance or confli ct is a symptom of a d}'sfunc tion in the individual, as described above. A common misconception is that a classification of mental disorders classifies pea-pie, when actually w hat a re being classified are disorders tha t people h ave. For this reason, the text of DSNHV (as did the text of DSM-WR) avoids the use of s uch expressions as "a schizophrenic" or "an alcoholic" and instead uses the more accurate, but admittedly more cumbersome, "an ind ividual w ith Schizophrenia" or "an individual with Alcohol Dependence."
I xxxii
Int roduction
clinical information that goes beyond diagnosis. In recognition of the heterogeneity of clinical presentations, DSM-IV often includes polythetic criteria sets, in which the individual need only p resent w ith a subset of items from a longer list (e.g., the diagnosis of Borderline Persona lity Disorder requires only five out of nine items). It was suggested that the DSM-IV Classification be organized foUowing a dimensional model rather than thecategorica l model used in DSM-lII-R. A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment to categories and works best in describing phenomena that a re distributed continuously and that do not have clear boundaries. Although dimensional systems increase reliability and communicate more clinical informati on (because they report clinical attribp tes that might be subthreshold in a categorical system), they also have serious limitati~s and thus far have been less useful than ca tegorica l systems in clinical practice and in s timulating research . N umerical dimensional descriptions are much less familiar and vivid than are the categorical names fo r men tal d isorders. Moreover, there is as yet no agreement on the dlOice of the optimal dimensions to be used for classification purposes. ' onetheless, it is possible that the increasing research on, and familiarity with. dimensional systems may eventually result in their greater acceptance both as a method of conveying clinical information and as a research tool.
Introduct ion
,
XXXIII
used or misunderstood. These dangers arise because o f the imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagnosis. In most situations, the clinical diagnosis of a OSM-N mental disorder is
not sufficient to establish the existence for legal purposes of a "mental disorder,"
"mental di sability," "m ental disease," or "mental d efect." In determining whether an individual meets .1 s pecified legal s tandard (e.g ., fo r competence, criminal resp onsibility, or disability), additional information is usually required beyond that contained in the OSM-IV diagnosis. This might include information abou t the individual's functional impairments and how these impairments affect the particular abilities in question. It is precisely becau se impairments, abilities, and disabilities vary w idely within each diagnostic category that assignment of a particular d iagnosis does not imply a specific level of impairment or d isab ility. Nondinical decision makers should also be cautioned that a diagnosis does not ca rry any necessary implications regarding the causes of the individual's m enta l dis order or its associated impairments. Inclusion of a d isorder in the C lassifi cation (as in medicine generally) does not require that there be knowledge about its etiology. Moreover, the fact that an individual's presentation meets the criteria for a OSM IV diagnosis d oes not carry any necessary implication regarding the individual's d egree of control over the behaviors that may be associated with the disord er. Even when di minished con trol over one's behavior is a feature of the disorder, having the d iagnosis in itself d oes not demonstra te that a particular individual is (or was) unable to control his or her behavior at a particular time. It must be noted that DSMIV reflects a consensu s about the cla ssification and di agnosis of mental disorders d erived at the time of its initia l publica tion. New knowl edge generated by research or clinical experience will undoubtedly lead to an increased Wlderstanding of the disorders included in DSMIV, to th e identification of new disorders, and to the removal of some disorders in futu re classifications. The text and criteria sets included in DSMIV will require reconsidera tion in light of evolving new information. The use of DSMIV in forensic settings should be informed by an awareness of the risks and limitations d iscussed above. When used appropriately, d iagnoses and diag nostic information can assist decision makers in thei r determinations. For example, when the presence of a mental di sorder is the predicate for a subsequent legal deter mination (e.g., involwltary civil commitment), the use ohm, es tablished system of diagnosis enhances the value and reliability of the determination . By providing a com pendirnn based on a review of the pertinent clinical and research literature, OSrvH V may facilitate the legal decision makers' unders tanding of the relevant characteris tics of mental disorders. The literature related to diagnoses also serves as a check on un grounded speculation about mental disorders and about the functioning of a particular individual. Finally, d iagnostic information regarding longitudinal course may improve decision making when the legal issue concerns an individ ual's mental func tioning at a pas t or future point in time.
XXXIV
Introduction
intemationally. Clinicians arc cal led on to evaluate ind ividua ls from numerous different ethnic groups and cultural backgrounds (including many w ho are recent immigrants). Diagnostic assessment can be especially ch alle nging when a clinician from one ethnic or cultural g roup uses the OSM-JV Classification to evaluate an ind ividual from a different ethnic or cultural group. A clinician who is unfamiliar w ith the nuances of an ind ividual's culhtral fram e of reference may incorrectly judge as psycho--
--------------------------------Introd uction
xxxv
able addi tional information about the person being evaluated beyond tha t required to make a DSM~IV d iagnosis.
Cautionary Statement
T he specified diagnos tic criteria for each mental disorder are offered as guidelines for making diagnoses, because it has been demonstrated that the use of s uch criteria
enhances agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills. These diagnostic criteria and the DSM-JV Classification of mental disorders reflect a consensus of current fo rmuJations of evolving knowledge in our field . They do not
encompass, however, all the conditions for which people may be treated or that may
XXXVII
teria fo r the disorder are currently met. In deciding whether the presentation should
be d escribed as mild, mode rate, or severe, the clinician should take into account the number and in tensity of the signs and symptoms of the disorder and any resulting impairment in occupatioQal or social functioning . For the majority of disorders, the following guidelines may be used : Mild. Few, if a ny, symptoms in excess of those required to make the diagnos is are present, and symptoms result in no more than minor impairment in social or occupa tional fun ctioning. Moderate. Symptoms or functional impairment betw"een "mild " and "severe" are present. Severe. Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, a re present, or the symptoms result in marked impairment in social or occupational functioning. In Partial Remission. The full criteria for the disorder were previously met, but currently only some of the s}'l1lptoms or signs of the disorder remain. In Full Remission. There are no longer any symptoms or signs of the disorder, but it is still clinically relevant to note the disorder-for example, in an individual w ith previous episodes of Bipolar Disorder who has been symptom free on lithium for the past 3 years. After a period of time in full remission, the clinician may judge the individual to be recovered and, therefore, would no longer code the disorder as a current diagnosis. The differentiation of In Full Remission from recovered requires consideration of many factors, including the cha racteris tic course of the disorder, the length of time since the Jast period of disturbance, the total duration of the disturbance, and the need for continued evaluation or p rophylactic trea tment. Prior History. For some purposes, it may be useful to note a history of the criteria having been met for a disorder even when the individual is considered to be recovered from it. Such past diagnoses of mental disorder would be indicated by using the specifier Prior His tory (e.g., Separation Anxiety Di sorder, Prior History, for an individual w ith a history of Separation Anxiety Disorder who has no current disorder or who currently meets criteria for Panic Disorder). Specifi c criteria for defining Mild, Moderate, and Severe have been provided for the follow ing: Men tal Retardation, Conduct Disorder, Manic Episode, and Major Depressive Episode. Specific criteria for defining In Partial Remission and In Full Remission have been provided for the follo wing: Manic Episode, Major Depressive Episode, and Subs tance Dependence.
Recurrence
Not infrequently in clinical practice, individuals after a period of time in which the full criteria for the disorder are no longer met (i .e., in partial or full remission or recovery) may develop symptoms that suggest a recurrence of their original disorder but that do not yet meet the full threshold for that d isorder as sp ecified in the criteria set. It is a matter of clinical judgment as to how best to indicate the presence of these symptoms. The following options are available:
If the symptoms are judged to be a new episode of a recurrent condition, the disorder may be diagnosed as current (or provisional) even before the full criteria have been met (e.g., after meeting criteria for a Major Depressive Episode for only 10 days instead of the 14 days usually required). If the symptoms are judged to be clinically s ignificant but it is not clear w hether they constitute a recurrence of the original disorder, the appropriate Not Otherwise Specified category may be given. If it is judged that the symptoms are not clinically significant, no additional current or provisional diagnosis is given, but "Prior History" may be noted (see p. 2).
Provisional Diagnosis
The specifier provisional can be used when there is a strong presumption that the full criteria w ill ultimately be met for a disorder, but not enough information is available
Use o f the Manual to make a firm diagnosis. The clinician can indicate the d iagnostic uncertainty by recording "(provisional)" following the diagnosis. For example, the ind ividuaJ appears to have a Major Depressive Disorder, but is unable to g ive an adequate history to establish that the full criteria are met. Another use of the term provisional is for those situations in w hich differential diagnosis depends exclusively on the duration of illness. For example, a diagnosis of Schizophrenifonn Disord er requires a duration of less than 6 mon ths and can only be given provisionally if assigned before remission has occurred.
5
Examples of clinical situations
Term
V Codes (for Other Cond itions That May
Insufficient information to know whether or not a presenting problem is attributable to a mental disorder, e.g., Academic Problem; Adult Antisocia l Behavior
799.9 Diagnosis or Condition Deferred on Information inadequate to make any diag nostic judgment about an Axis I d iagnosis or Axis I condit ion 799.9 Diagnosis Deferred on Axis I[ 300.9 Unspecified Mental Disorder (non psychotic) 298.9 Psychotic Disorder Not Otherwise Specified Information inadequate to make any diagnostic judgment about an Axis II diagnosis Enough information avai lab le to rule out a Psychotic Disorder, but further specification is not possible Enough infor mation avai lable to determine the presence of a Psychotic Disorder, but fur ther specification is not possi ble
[Class of disorder! Not Otherwise Specified Enough information available to indicate the class of disorder that is present, but fure.g ., Depressive Disorder Not Otherwise ther specification is not possible, e ither beSpecified cause there is not sufficient information to make a more specific diagnosis or because the clinical features of the disorder do not meet the criteria for any of th e specific cate gories in that class [Specific diagnosis) (Provisional) e.g ., Schizophreniform Disorder (Provisional) Enough information available to make a "working " d iagnosis, but the clinician wishes to indicat e a significant degree of diagnostic uncertainty
' -
Criteria Used t o Excl ude Other Diagnoses and to Suggest Differential Diagnoses
Most of the criteria sets presented in this manual include e xclusion criteria that are necess ary to establish boundaries between disorders and to clarify differential diagnoses. The several different wordings of exclusion criteria in the criteria sets throughout DSM-lV reflect the different types of possible relationships among disorders: "Criteria h ave n ever b een m e t for . .." This exclusion criterion is used to define a lifetime hierarchy between d isorders. For example, a diagnosis of Major Depressive Disorder can no longer be given once a Manic Episode has occurred and must be changed to a diagnosis of Bipolar I Disorder.
"Criteria are not m et for ... " This exclusion criterion is used to establish a hierarchy behveen disorders (or subtypes) defined cross-sectionally. For example, the specifier With Melancholic Features takes precedence over With Atypical Features for d escribing the current Major Depressive Episode. "does not occur exclusively during the course of ... " lhis exclusion criterion prevents a disorder from being diagnosed when its symptom presentation occurs only during the course of another disorder. For example, dementia is not diagnosed separately if it occurs only during delirium; Conversion Disorder is not diagnosed separately if it occurs only during Somatization Disorder; Bulimia 'ervosa is not diagnosed separately if it occu rs only during episodes of Anorexia ervosa. This exclusion criterion is typically used in situations in which the symptoms of one disorder are 'a ssociated features or a subset of the symptoms of the preempting disorder. The clinician should consider periods of partial remission as part of the "course of another disorder." It should be noted that the excluded d iagnosis can be given at times when it occurs independently (e.g., when the excluding disorder is in full remission). " not due to the direct physiological effects of a su bstance (e.g., a drug of abuse, a m edication) or a general medical condition." lhis exclusion criterion is used to indicate that a substance-induced and general medical etiology must be consid ered. and ruled out before the disorder can be d iagnosed (e.g., Major Depressive Disorder can be diagnosed. only after etiologies based on substance use and a general medical condition have been ruled out). "not better accounted for by ... " This exclusion criterion is used 10 indicate that the disorders mentioned in the criterion must be considered in the differential diagnosis of the presenting psychopathology and that, in boundary cases, clinical judg ment will be necessary to determine wh ich d isorder provides the most appropriate diagnOSiS. In such cases, the " Differential Diagnosis" section of the text for the d isorders should be consulted for guidance. The general con vention in DSM-IV is to allow multiple diagnoses to be assigned for those presentations that meet criteria for more than one DSM-IV disorder. There are three situations in which the above-mentioned exclusion criteria help to establish a diagnostic hierarchy (and thus prevent multiple diagnoses) o r to highlight differential diagnostic considerations (and thus discourage multiple d iagnoses): When a Mental Disorder Due to a General Medical Cond ition or a SubstanceInduced Disord er is responsible for the symptoms, it preempts the diagnosis of the corresponding p rimary disorder with the same symptoms (e.g., Cocaine-Induced. Mood Disorder preempts Major Depressive Disorder). In such cases, an exclusion crilerion containing the phrase "not due to the direct physiological effects of ... " is included in the criteria set for the primary disorder. When a more pervasive disorder (e.g., Schizophrenia) has among its defining symptoms (or associated symptoms) what are the defining symptoms of a less pervasive disorder (e.g., Dysthymic Disorder), one of the following three exclusion criteria appears in the criteria set for the less pervasive disorder, indicating that only the more pervasive disorder is diagnosed: "Criteria have never been met for ... ," "Criteria are not met for ... ," "does not occur exclUSively during the course 0 f . . . ..
Use of the Man ua l When there are particularly difficult d ifferential diagnostic boundaries, the phrase "not better accounted for by ... " is included to indicate tha t clinical judgment is necessary to determine w hich diagnosis is most approp riate. For exam ple, Panic Disorder With Agoraphobi a includes the criterion "not better accounted for by Socia l Phobia" and Social Phobia includes the criterion " no t better accounted. fo r by Panic Disorder With Agoraphobia" in recognition of the fac t that this is a particul arly d ifficult bounda ry to draw . In some cases, both d iagnoses might be ap propriate.
Withdrawal, med ica tion use, or toxin exposure. In an effort to provide some assistance in making this determination, the two criteria listed below have been add ed to each of the Substance-Induced Disorders. These criteria are intended to provide general gu idelines, b ut at the same time allow for clinical judgment in d etermining whether or not the presenting symptoms are best accounted for by the direct ph ysiologica l effects of the substance. For fur ther discussion of this issue, see p . 209.
B.
There is evidence from the history, physical exa mination, or laboratory findin gs of either (1) or (2): (1) the sym ptoms developed during, or with in a month o f, Substance In toxication or Withdrawal (2) medication use is etiologically rela ted to the disturbance
C.
The disturbance is no t better accounted fo r by a disorder that is not substance induced . Evidence that the sym p toms are better accounted for by a d isord er that is not substance induced might includ e the following: the symptoms precede the onset o f the substance use (or medication use); the symp toms persist for a substantial period of time (e.g., about a month) aft er the cessation of acute withdrawal or severe intoxication, or are substantially in excess of w hat would be expected given the type, duration, or amount of the substance used ; or there is o ther ev i denc~ that suggests the existence of an independent non-substance-induced d isord er (e.g., a history o f recurren t non-substance-related episodes).
8
Criteri a f o r Clini cal Significance
Use of t he Manua l
The defi ni tion of mentul disorder in the introduction to DSM-IV requires that there be clinically significant impainnent or distress. To highlight the importance of considering this issue, the cri teria sets for most disorders include a clinical significance crite-rion (usually w orded " ... causes clinically significant distress or impairment in social, occu pational, or other important areas of functionin g"). This criterion help!" ('stablish
the threshold fo r the diagnosis of a disorder in those s ituations in which the symptomatic presentation by itself (par ticu larly in its milder forms) is not inherently pa thological and may be encQwltered in individuals for whom a diagnosis of " mental disorder" wou ld be inappropria te. Assessing whether this criterion is met, especially in terms of role funqion, is an inherently difficu lt clinical judgment. Reliance on information from family members and other third parties (in addition to the individual) regarding the individual's performance is o ften necessary.
Associated descriptive feat llres alld melltal disorders. 1llis section includes clinical fea tures tha t are frequently associated w ith the disord er but that are not considered essential to making the diagnosis. In some cases, these features were considered for inclusion as possib le diagnostic criteria but were insufficiently sensitive or specific to be included in the final criteria set. Also noted in this section are other mental disorders associa ted w ith the disorder being discussed. It is specified (when known) if these disorders p recede, co-occu r with, or are consequences of th e djsorder in question (e.g., Alcohol-Induced Persis ting Demen tia is il consequence
of chronic Akohol Dependence) . If a vailable, information on predisposing fac tors and complica tions is also included in this section . Associated /aboratoryjifldiflgs. This section prov ides information on three types of laboratory findings that may be associated w ith the disorder: 1) those associated laboratory findings that are considered to be "diagnostic" of the disorder- for example, polysonmog ra phic findings in certain sleep disorders; 2) those associated laboratory findings that are not considered to be diagnostic of the disorder but that have been noted to be a bnormal in groups of individuals w ith the dis order relative to control subjects-fo r example, ventricle size on computed tomography as a valida tor of the construct of Schizophrenia; and 3) those laboratory findings that are associated with the complications of a disorder-for example, electroly te imbalances in individuals with Anorexia Nervosa . Associated pizysical examillatio1l .Iii/dings alld gelleral medical cOllditiolls. This section incl udes information about symptoms elicited by his tory, or fi.ndings noted during physical examination, that may be of d iagnostic significance but that are not essential to the diagnosis-for example, dental erosion in Bulimia Nervosa. Also included are those disorders that are coded outs ide the "Mental and Behavioural Disord ers" chapter of rCD that are associated w ith the disorder being discu ssed . As is done for associated me ntal disorders, the type of associa tion (i .e., precedes, co-occurs w ith, is a consequence of) is specified if know n-for example, that cirrhosis is a consequence of Alcohol Dependence. Specific Culture, Age, and Gender Features. This section provides guidance for the clinician concerning variations in the presentation of the disorder that may be attributable to the individual's cultural setting, developmental s tage (e.g., infancy, childhood , adolescence, adulthood, late We), or gender. This section also includes informa tion on differential prevalence rates related to culture, age, and gender (e.g., sex ratio). Prevalence. This sec tion provid es a vailable data on poin t a nd lifetime prevalence, incidence, a nd lifetime ris k. These data are provided for different settings (e.g ., community, primary care, outpatient m enta l health cl inics, and inpatient psychiatric settings) w hen this information is known . Course. llUs section describes the typical lifetime patterns of p resenta tion and evolution of the disorder. It contains information on typical age at ollset and mode of ollset (e.g., abrupt or insidious) of the disord er; episodic vers us cOlltillllOIlS course; single episode versus rewrrent; duratioll, characterizing the typical length of the illness and its episodes; and progressioll, describing the general trend o f the disorder over time (e.g., stable, worsening, improving). Familial Pattern. This section describes data on the frequency of the disorder among firs t-degree biological relatives of those w ith the disorder compared with the frequency in the general population. It als o indicates o ther disorders that tend to occu r more frequ en tly in famil y members of those with the disorder. Information regarding the heritable n ature of the disorder (e.g., d ata from h vi..n studies, known genetic t.ransmission patterns) is also included in this section .
10
Differential Diagnosis. This section discusses how to differentiate this disorder from other d isorders that have some simila r presenting characteristics.
Appendix A: Decision Trees for Differential Diagnosis. This appendix contains six decision trees (for Mental Disord ers Due to a General Medical Condition, Sub-
11
stance-Induced Disorders, Psychotic Disorders, Mood Disorders, Anxiety Disorders, and Somatoform Disorders). Their purpose is to aid the clinician in differential diagnosis and in understanding the hierarchical struchtre of the DSM-IV Classification. Appendix B: Criteria Sets and Axes Provi ded for Further Study. This appendix contains a nwnber of proposals that were suggested. for possible inclusion in DSM-IV. Brief tex ts and research criteria sets are provided for the following: postconcussionai disorder, mild neurocognitive disorder, caffeine withdrawal, p ostpsychotic depressive disorder of Schizophrenia, simple deteriorative disorder, premenstrual d ysphoric disorder, minor depressive disorder, recurrent brief depressive di sorder, mixed anxiety-depressive disorder, factitious disorder by proxy, dissociative trance disorder, binge-eating disorder, depressive personality disorder, passive-aggressive personal ity disorder, Neuroleptic-Induced Parkinsonism, Neuroleptic Malignant Syn drome, Neuroleptic-Induced Acute Dystonia, Neuroleptic-Induced Acute Akathisia, Neuroleptic-Induced Tardive Dyskinesia, and Medication-Induced Poshtral Tremor. In addition, alternative dimensional d escriptors for Schizophrenia and an alternative Criterion B for Dysthymic Disorder are included . Finally, three proposed axes (Defensive Functioning Sca le, Global Assessment of Relational Functioning [GARF] Scale, and Social and Occupational Flmctioning Assessment Scale [SOFAS)) are prov ided. Appendix C: Glossary of Technical Terms. This appendix contains glossary definitions of selected terms to assist users of the manual in the application of the criteria
>els.
Appendix D: Highligh ts of Changes in DSM-IV Text Revision. This appendix provides an overview of changes as a result of the DSM-fV text revision process. Appendix E: Alphabetical listing of DSM-JV-TR Diagnos es and Codes. This appendix tis ts the DSM-fV disorders and conditions (with their ICD-9-CM codes) in alphabetical order. It has been included to facilita te the selection of diagnostic codes. Appendix F: Numerical Listing of DSM-IV-TR Diagnoses and Codes. This appendix lists the DSM-fV disorders and conditions (wit..b..tt:eir ICD-9-CM codes) in numerical order by code. It has been included to facilita te recording of diagnostic terms. App en dix G: ICD-9-CM Co des for Selected General Medical Conditions and Medication-Induced Disord ers. This appendix contains a list of ICD-9-CM codes for selected general medical conditions and has been provided to fa cilitate coding on Axis ill. This appendix also provides KD-9-CM E-codes for selected medications, prescribed at therapeutic dose levels, that cause Substance-Induced Disorders. The E-codes may optionally be coded on Axis I immediately following the related disorder (e.g ., 292.39 Oral Contraceptive-Induced Mood Disorder, With Depressive Features; E932.2 oral contraceptives). App endix H: DSM-IV Classification (With ICD-lO Codes). As of the publ.ication of the text revision (in the late spring of 2000), the officia l coding system in use in the
United States is the hltematiollal Classification of Diseases, Ninth Revision, C linical Modification (ICO-9-CM). Throughout much of the world, the officia l coding system is the IlltenliltiOlla/ Sflltistiml Classification of Diseases aud Related Healtll Problems, Tenth Rev ision (lCO10). To facilita te the use of DSMIV internationally, this appendix contains the complete OSMIV classification with IC D10 diagnostic codes. Appendix I: Outline fo r Cultural Fonnulation and Glossary of Cul tureBound Syndromes . This appendix is divided into hvo sections. The firs t provides an outline for cultural formulation d esigned to assist the clinician in systematically evaluating and reporting the impact of the individual's cultural context. The second is a glossary of culture-bound syndromes. Appendix J: DSMrv Contributors. This appendix lists the names of the advisers and field-trial participants and other individuals and organiza tions that contributed to the development of OSMIV. Appendix K: DSMrv Text Revision Advisers. This appendix lists the names of the advisers who contributed to th e OSMIV Text Revision.
- ~
DSM-IV-TR Classification
An ellipsis (. . .) is used in the nam es of certain disorders to indicate that the name of a specific mental disorder o r general medical condition should be inserted when recording the name (e.g., 293.0 Delirium Due to Hypothyroidism). Numbers in parentheses are page numbers.
U criteria are currently met, one of the
These are coded 011 Axis 11. Mild Mental Retardation (43) Moderate Mental Retardation
(43)
Severe Mental Retardation (43) Profound Mental Retarda tion (44) Mental Retardation, Severity Unspecified (44)
If criteria arc no longer met, one of the follow ing specifiers may be noted:
In Partial Remission In Full Remission Prior His tory
315.00 Reading Disorder (51) 315.1 Mathematics Disorder (53) 315.2 Disorder of Written Expression (54) 315.9 Learning Di sorder NOS (56)
MOTOR SKILLS DISORDER (56) , ,
315.4
315.32 Mixed Receptive-Expressive Language Disorder (62) 315.39 Phonological Disorder (65) 307.0 Shlttering (67) 307.9 Communication Disorder NOS
(69)
13
OTHER DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE ( 121) 309.21 Separation Anxiety D isorder (121)
Spify if: Earl)' Onset
307.3
313.9
FEEDING AND EATING DISORDERS OF INFANCY OR EARLY CHILDHOOD (103) 307.52 Pica (103) 307.53 Rumination Disorder (105) 307.59 Feeding Disorde r of Infancy or Early Childhood (107)
TIC DISORDERS (108) 307.23 Tourette's Disorder (1 11) 307.22 Chronic Motor or Vocal Tic Disorder (114) 307.21 Transient Tic Disorder (11 5)
Spify if: Single Episode/ Recurrent
,
DSM -IV-TR Classification -.Delirium Due to M ultiple Etiologies (code each ofllle specific
294.lx Dem entia Due to Pick's Disease (also code 331.1 Pick's disease all Axis 11l) (165) 294 .1 x De me nti a Due to Creutz fe ldt}ilkob Disease (a lso code 046.1
etiologies) (146)
780.09 Delirium N O S (147)
DEMENTIA (147) 294 .xx De me ntia of the Alz he ime r's Type, With Early Onset (also code 33 1.0 Alzheimer's disease 011 Axis lll) (1 54) .10 Witho u t Behavio ral Disturbance .11 With Behavioral Distu rbance 294 .xx Demen tia of the Alzheimer's Type, With Late Onse t (also code
General Medical Condition not listed above] (also code ti,e general medical conditioll on Axis lll) (167)
Substance-Lnduced Persis ting Dem e ntia (refer to SlIbstallce-
294 .8
AD
.41 .42
.43
Code presence or absence of a belJaviornl disturbmlce ill tile fifth digit for Dem entia
Due to a Genera l Medical Cond itio n:
294.1x Dem entia Due to rnv Disease (also code 042 HlV a / I Axis III)
(163)
294. lx Dem e ntia Due to H ead Trauma (also code 854.00 head illj ury all Axis Ill) (164) 294.1x De mentia Due to Pa rkinson 's Disease (also code 332.0 ParkinSOIl's disease all Axis Ill) (164) 294.1x Dem entia Due to H unting to n's Disease (also code 333.4 HUlltingtall '5 disease all Aris lll) (165)
I
I
293.89
DSM-IV-TR Classification
S;/eCify IYl'e: La bile Type/ Disinhibited T),pe/ Aggressive Type/ Apatheti c Trpe/ Paranoid Trpe / Other Type/ Combined Type/ Unspecifi ed Type
293.9
Substance-Related Disorders
( 191 )
291.89 291.9
Alcohol-Induced Psychotic Disorder (338) With Delu sions!.w With Hallucinations',w Alcohol-induced Mood Disorde~'w (405) Alcohol-Induced Anxiety Disorde~'w (479) Alcohol-Induced Sexual Dysfun ction' (562) Alcoh ol-Induced Sleep Disorder],w (655) Alcoh ol-Rela ted Disord er OS
(223)
bEady Full Remission / Early Partial Remission/ Sustained Full Re mission / Sustained Parti al Remission 9"n a Controlled Environment dOn Agonist Thera py
Amphetamine Use Disorders (224) 304.40 Amphetamine Dependenceilo,b,C (224) 305.70 Amphetamine Abuse (225) Amphetamine-Induced Disorders
(2 26)
292.0
Amphetamine Withdrawal
(227)
Alcohol Use Disorders (213) 303.90 Alcohol Dependencea,b,c (213) 305.00 Alcohol Abuse (214) Alcohol-Induced Disorders (214) 303.00 Alcohol In toxication (214) 291.81 Alcohol Withdrawal (215)
Spify if: With Perceptual Disturbances
Alcohol-Ind uced Persisting Dementia (168) Alcohol-Induced Persisting Amnestic Disorder (177)
292.81 Amphetamine Intoxication Delirium (143) 292.xx Amphetamine-Induced Psycho tic Disorder (338) .11 With Delusions' .12 With Ha llucinations l 292.84 Amphetamine--lnduced Mood Disord erl,w (405) 292 .89 Amphetam ine-lnducedAnxiety Disorder' (479) 292.89 Amphetamine--Induced Sexual Dysfunction ' (562) 292.89 Amphetamine-Induced Sleep Disorder!'w (655) 292.9 Amphetamine-Related Disorder NOS (231)
Caffeine-Induced Disorders (232) 305.90 Caffeine into)cication (232) 292.89 Caffeine-induced Anxiety Disorder! (479) 292.89 Caffeine-Induced Sleep Disorder! (655) 292.9 Ca ffein e-Related Disorder NOS (234)
CANNABIS-RELATED DISORDERS (234 )
292.84 Cocaine-induced Mood Disorderl,W (405) 292.89 Cocaine-Induced Anxiety Disorder!,w (479) 292.89 Cocaine-Induced Sexual Dysfunction l (562) 292.89 Cocaine-Induced Sleep Disorder['\\' (655) 292.9 Cocaine-Related Disorder NOS
(250)
HALLUCINOGEN-RELATED
DISORDERS (250)
Cannabis Use Disorders (236) 304.30 Cannabis Dependence<l,b,C(236) 305.20 Cannabis Abuse (236) Cannabis-Induced Disorders (237) 292.89 Cannabis intoxication (237) sp.."'CifiJ if: With Perceptual Dis turbances 292.81 Cannabis intoxication Delirium (143) 292.xx Cannabis-Induced Psychotic Disorder (338) .11 With Delusions! .12 With Hallucinations1 292.89 Cannabi s-Induced Anxiety Disorder! (479) 292.9 Cannabis-Related Disorder NOS (241)
COCAINE-RELATED DISORDERS (241)
Hallucinogen Use Disorders (25 1) 304.50 Hallucinogen Depend enceb,c (251) 305.30 Hallucinogen Abuse (252) Hallucinogen-Induced Disorders
(25 2)
Coca in e Use Disorders (242) 304.20 Cocaine Dependencea,b,( (242) 305.60 Cocaine Abuse (243) Coca ine-Induced D isorders (244) 292.89 Cocaine Intoxica tion (244)
S/N~ify
292.89 Hallucinogen Intoxication (252) 292.89 Hallucinogen Persisting Perception Disorder (Flashbacks) (253) 292.81 HallUCinogen Lntoxication Delirium (143) 292.xx Hallucinogen-Ind uced Psychotic Disorder (338) .11 Wi th Delusions' With Hallucinations! .12 292.84 Hallucinogen-Ind uced Mood Di sorder! (405) 292 .89 Hallucinogen-Ind uced Anxiety Di~orderl (479) , 292.9 HallucinogenRelated Disorder
NOS (256)
INHALANTRELATED DISORDERS
(257)
Inhalant Use Disorders (258) 304.60 Inhalant Dependenceb,c (258) 305.90 Inhalant Abuse (259) Inhalant-Induced Disorders (259) 292.89 Inhalant Intoxication (259) 292.81 Inhalan t In toxication Delirium (143)
292.xx Cocaine-induced Psychotic Disorder (338) .11 Wi th Delusions' With Hallucinations! .12
DSM-IV-TR Classification
PHENCYCLIDINE (OR PHENCYCLIDINE-L1KE)-RELATED DISORDERS (278)
292.82 Inhalant-Induced Persisting Deme ntia (168) 292.xx Inhalant-Ind uced Psychotic Disorder (338) W ith Delusio ns l .11 With Hallucinationsl .12 292.84 Inhalant-Induced Mood Disorder l (405) 292.89 Inhalant-Induced Anxiety Disorderl (479) 292.9 Inhalant-Rel<!.!ed Disorder NOS (263)
NICOTINE-RELATED DISORDERS
(264)
292.81 292.xx
Nicotine Use Disorder (264) 305.1 N icotine Depe ndencea,b (264) Nicotine-Induced Disorder (265) 292.0 N icotine Withdrawal (265) 292.9 Nicotine-Rela ted Disorder NOS
(269)
OPIOID-RELATED DISORDERS (269)
Phe ncyclidine Intoxication Delirium (143) Phe ncyclidine-Induced Psychotic Disorder (338) With Delusions l With H allucinations! Phe ncyclidine-Induced Mood Disorde~ (405) Phencyclidine-Induced Anxiety Disorde~ (479) Phe ncyclidine-Rela ted Disorder NOS (283)
Opioid Use Disorders (270) 304.00 Opioid Dependenceil,b,c,d (270) 305.50 Opioid Abuse (271) Opioid-Induced Disorders (27 1) 292.89 Opioid Intoxication (271)
Spify if With Perceptual Disturbances
Sedative, Hypnotic, or Anxiolytic Use Disorders (285) 304.10 Sedative, H ypnotic, or Anxiolytic Dependencea,b,c
(143) Opioid-Induced Psychotic Disorde r (338) With Delusionsl With H allucinationsl Opioid-Induced Mood Disorder l (405) Opioid-Induced Sexual Dysfu nction l (562) Opioid-Induced Sleep Disorde~'w (655) Opioid-Related Disorder NOS (277)
292.81
Sedative, H ypnotic, or Anxiolytic Intoxica tio n Delirium (143) 292.81 Seda tive, H ypnotic, o r Anxiolytic W ithdrawal Delirium (143)
292.82 Seda tive-, H ypnotic, o r Anxiolytic-Induced Persisting Dementia (168) 292.83 Sedative-, Hypnotic-, or Anxiolytic-lnduced Persisting Amnestic Disorder (177) 292.xx Sedative-, Hypnotic-, o r Anxiolytic-Induced Psycho tic Disorder (338) .11 With Delusions'-\\' .12 With Hallucinations l,\\' 292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder i ,\\' (405) 292.89 Seda tive-, H ypnotic-, or Anxioly tic-Induced Anxiety Disorder\\' (479) 292.89 Sedative , H ypno tic , or
Anxiolytic.Induced Sexu al Dysfunctionl (562) 292.89 Sedative, H ypnotic , o r Anxiolyticlnduced Sleep Dis orde r'-w (655) 292.9 Seda tive, H y pnotic-, o r A nxiolytic-Related Dis orde r N OS (293)
292.0
292.81 O ther (or Unknown) Substance-Induced Delirium (143) 292.82 Other (or Unknown) Substance-Induced Persisting Dementia (168) 292.83 Other (or Unknow n) Substance-Ind u ced Persisting Amnestic Disorder (177) 292.xx Other (or Unknown ) Substance-Induced Psychotic Disorde r (338) .11 With Delus ions)'W With Hall ucina tionsi,w .12 292.84 O ther (or Un known)
Subs tance-Induced Mood Diso,de~'1V (405) 292.89 Other (or Un known) Subs tance-Ind uced Anxie ty Disord erl.l\' (479) 292.89 Other (or Unknow n) Substance-Induced Sexu a l Dysfunctio n! (562) 292.89 O ther (or Unknown) Subs tance-Ind uced Sleep Diso ,de~'1V (655) 292.9 O ther (or Unknown) Su bs ta nce-Related Disorder NOS (295)
POLYSUBSTANCE-RELATED
DISORDER (293)
..,
Schizophrenia and Other
Abuse (198)
Other (or Unknown) SubstanceInduced Disorders (295) 292.89 O the r (or Unknow n) Subs tance Intoxicatio n (199)
S,lt(ify if. With Perceptua l Distu rbances
Continuous (specify if. With Prominent Negati\'e Symptoms) Single Episode In I'artial Remission (specify if: With Prominent Negative Symptoms)/ Single Episode In Full Remission Other or Unspecified I'altem
Paranoid T ype (313) D isorgan ized T ype (31 4) Ca ta lo n icType (315) Und iffe re ntiate d T y p e (316) Res idual Type (316)
Code currellt state of Mnjor Depressive Disorder or Bipo/ar I Disorder ill fiftll digit
l" M ild 2" :-" loderate 3 "Se\'cre Without l'sycholic Features .,\ "Severe With Psychotic Features Sprcify: Moad--Congruent I'sychotic Fl'atures /~ load-Incongruent Psychotic Features 5" In Partial Remission 6 '" In Full Remission 0:. Unspecified
fa
"Se\erity / Psychotic/ Remission Specifiers / bChronic/ "With Catatonic Features/ d\\'ith ~" clancholic Featurt'S / t With Atypical FeatureslWith Postpartum Onset
.3x
300.4
Recurren ta,b,c,d,e.f,g..h D ys th ymic Disor d er (376) Spify if: Early Onset/ Late Onset Sprcify: With Atypical Featurt'S Depr e ssive Disorder NOS (381
311
298.9
296.xx .Ox
Bipolar J D is order (382) S ing le M an ic Epis odea,c,f Specify if Mixed .40 Mos t Recent Episode H y p omanic&<h.i
.4x
21
300.3
Obsessive-Compu lsive Disorder (456) Specify if: With Poor Insight Posttrauma tic Stress Disorder (463) Sp<'cify if" Acute/ Chronic specify if With Delayed Onset Acu te Stress Disorder (469) Generalized Anxiety Disorder (472) Anxiety Disorder Due to . . . [ll/dicafe the Gel/eral Medical COl/ditiol/] (476) specify if With Generalized Anxiety/ With Panic Attacks/ With ObsessiveCompulsive Symptoms Subs tance-Induced Anxiety Disorde r (refer to SlIbstanceRelated Disorders for s/lbstal/cespecific codes) (479) Sprcify if: With Generalized Anxiety/ With Panic AHacks/ With ObsessiveCompulsive Symptoms/ \\,ith Phobic Symptoms Specify if: With Onset During Intoxication/ With Onset During \\'ithdrawal Anxiety Disorder NOS (484)
Most Recent Episode 1olixed a,.c,f,g,h,i Most Recent Episode Depressed a,b,c,d,e,f,g,h,i
309.81
.7
ryisode):
308.3 300.02
293.84
296.90
Hypomanic/ Depressed Cyclothymic Disorder (398) Bipolar Disorder NOS (400) Mood Disorder Due to . .. {II/dicate tilt' General Medical COllditioJl] (401 ) Specify IYI'e: With Depressive Features/ With f..lajor Dl'pressive--Likl' Episode/ With Manic Featurl's/ WHh MiXl'd Features Substance-Induced Mood Dis order (refer to SlIbstanceRelated Disorders fo r sllbstancespecific codes) (405) Spaify Iy/",: With Depressive Features/ With Manic Features/ With Mixed Features Specify if: With Onset During Intoxication/ With Onset During Withdrawal Mood Disorder N OS (410)
300.00
3OO.D1
300.21 300.22
300.29
300.2.3
Panic Disorder Without Agoraphobia (433) Pa nic Disorder With Agoraphobia (433) Agoraphobia Without His tory of Panic Disorder (441) Specific Phobia (443) SJNcify Iype: Animal Type/ Natural Environment Type/ Blood-InjectionInjury Type/ Situational Type/ Other Type Social Phobia (450) specify if: Generalized
Lifelong Type/ Acquired Type Generalized Type / Situational Type Due to Psychological Factors/ Due to Combined Fac tors
Sexual Desire Disorders (539) 302.71 Hypoactive Sexual Desire Disorder (539) 302.79 Sexual Aversion Disorder (541) Sexual Arousal Disorders (543) 302.72 Female Sexual Arousal Disorder (543) 302.72 Male Erecble Disorder (545) Orgasmic Disorders (547) 302.73 Female Orgasmic Disorder (547) 302.74 Male Orgasmic Disorder (550) 302.75 Premature Ejaculation (552) Sexual Pain Disorders (554) 302.76 Dyspareunia (Not Due to a General Medical Condition)
(554)
300.xx Factitious Diso rder (513) With Predominantly .16 Psychological Signs and Symptoms With Predominantly .19 Physical Signs and Symptoms ,,,,,' ith Combined .19 Psychological and Physical Signs and Symptoms 300.19 Factitious Disorder NOS (517)
(556)
300.12 Dissociative Amnesia (520) 300.13 Dissociative Fugue (523) 300.14 Dissociative Identity Disorder
(526)
Sexual Dysfunction Due to a General Medical Condition (558) 625.8 Female Hypoactive Sexual Desire Diso rder Due to ...
300.6
Depersonalization Disorder
(530)
Disorders (535)
[Indicate tile General Medicnl Condition] (55 8) 608.89 Ma le Hypoacti ve Sexual Desire Disorder Due to ... (Ind icate tile General Medical Conditioll) (558) 607.84 Male Erectile Disorder Due to . . . [Indicate the General Medical COllditioll } (558) 625.0 Female Dyspareunia Due to ... [lndicnte tile General Medical Condition } (558) 608.89 Male Dyspareunia Due to ... [Indicate ti,e General Medical Condition} (558)
DSM-IV-TR Classifi ca tio n 625.8 Other Female Sexual Dysfun ctio n D ue to ... [l ndicnte tile Geneml Medical Condition] (558) 608.89 Othe r Ma le Sexual Dysfu nction Due to ... [Jndica te the General Medical Condition} (558) Substance-Induced Sexual Dysfunction (refer to SubstallceRelated Disorders for slibstallcespecific codes) (562 )
Spu ify if: With Impaired DE's ire/ With Impaired Arousal / With ImpairE'd Orgasm / With Sexua l Pain Spl'dfy if: With Onset During Intox ication
307.1
Dyssomnias (598)
307.42 Primary InsoIImia (599) 307.44 Primary H ypersomnia (604)
Spaify if: Recu rrent
302.83 Sexu al Masochis m (572) 302.84 Sexual Sadism (573) 302.3 Transvestic Fetis his m (574)
spt'rify if: Wi th Gt' nder Dysphoria
347 Narcolepsy (609) 780.59 Brea thin g-Related Sleep D isorder (6 15) 307.45 Circadian Rhythm Sleep Disorder (622)
Specify typt': Delayed Sleep Phase Type / Jet Lag Type/ Shift Work Type/ Unspecified Typ e
Parasomnias (630)
307.47 307.46 307.46 307.47 N ighhna re Disorder (631) , Sleep Terror Disord er (634) Sleepw alking Disorder (639) Paras omnia NOS (644)
302.6 302 .9
SLEEP DISORDERS RELATED TO ANOTHER MENTAL DISORDER (645) 307.42 Insomnia Re la ted to .. . 1111dicate f1le Axis lor Axis 11 Disorder} (645) 307.44 H ypersomnia Rela ted to . . .
DSMIV TR Classification
OTHER SLEEP DISORDERS (651) 7BO.xx Sleep Disorder Due to ...
{Indicate the GellernI M edical
Conditio,,1 (651) Insomnia Type Hypersomnia Type Parasomnia Type Mixed Type
Disorder (refer to S/IbstflllceRelated Disorders for SlIbstfillee,
Sl'ecify lypt; Insomnia Type l
N ote:
301.0
(690)
301.20 Schizoid Pe rsonality Disorder
,- Substance-Induced Sleep
(694)
301.22 Schizotypai Personality Disorder (697) 301.7 Antisocial Personality Disorder (701) 301.S3 Borderline Personali ty Disorder
Hypersomnia Type/ Parolsomniil Type! Mixed Type Specify if With Onset During Intoxication/ With Onset During Withdrawal
(706)
301.50 His trionic Personality Disorder (711 ) 301.81 Na rcissis tic Personality Disorde r (714) 301.82 Avoidant Personal ity Disorder (71S) 301.6 Dep endent Personality Disorder (721) 301.4 Obsessive-Compuls ive Personality Disorde r (725) 301.9 Personality Disorde r NO S (729)
309.xx Adjustment Disorder (679) .0 With Dep ressed Mood .24 With Anxiety .28 With ivtixed Anxiety and Depressed Mood .3 With D is turbance of Conduct .4 With Mixed Disturba nce o f Emotions and Conduct .9 Unspeci fi ed
Spi'cify if: Acute / Chronic
PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION (73 1) 316 ... [Specified Psycllofogical Factor]
A!fectillg ... !Indicate tile General Medical Condition} (731) Choose /lame based 011 /lilt lire offactors:
Mental Disord er Affecting Medical Condition Ps)'choiogical Symptoms Affecting Medical Condi tion
DSM-IV-TR Cla ssification Personality Traits or Coping Style Affecting Medical Condition Maladaptive Hea lth Beh aviors Affecting Medical Condition Stress-Related Physiological Response Affecting Medica l Condition Other or Unspecified Psychological Factors Affecting Medical Condition
MEDICATION-INDUCED
MOVEMENT DISORDERS (734)
25
PROBLEMS RELATEO TO ABUSE OR NEGLECT (738)
victim)
all victim)
V61 .21 Neglect of Child (738) (code 995.52 ifJocus of attentioll is
all victim)
Physical Abuse of Adult (738) \/61.12 (if by partner) \/62.83 (if by person other than partner) (code 995.81 ifJaws of attelltioll is
all victim)
Neuroleptic-Induced Parkinsonism (735) Neuroleptic Malignant Syndrome (735) Neuroleptic-Induced Acute Dystonia (735) Neuroleptic-Induced Acute A kathis ia (735) Neuroleptic-Induced Tardive Dyskinesia (736) Medication-Induced Postural Tremor (736) Medication-Induced Moveme nt D isord er NOS (736)
- Sexual A buse of Adult (738) V61.12 (if by partner) V62.83 (iiby person other than partner) (code 995.83 ifJocus of attelltioll is
all
victim)
OTHER MEDICATION-INDUCED
DISORDER (73 6)
995.2
'oncompliance With Treatment (739) V65.2 Malingering (739) V71.01 Adult Antisocial Behavior (740) V71.02 Child or A dolescent Antisocial Behavior (740) V62.89 Borderline Intellechlal Functionin g (740)
No te: This is coded on Axis [I.
V15.81
V61.9
Relational Problem Related to a Mental Disorder or General Medical Condition (737) V61.20 Parent-Child Relational Problem (737) V61.10 Partner Relational Problem (737) V61.8 Sibling Rela tiona l Problem (737) V62.81 Relational Problem NOS (737)
780.9
V62.82 V62.3 V62.2 313.82 V62.89
Berea\'ement (740) Academic Problem (74 1) Occupational Problem (741 ) Identity Problem (741) Religious or SpirituaJ Problem
(741)
26
300.9
Diagnosis or Condition Deferred on Axis I (743) V71.09 No Diagnosis orv\xis II (743) 799.9 Diagnosis Deferred on Axis n (743)
799.9
Multiaxial Assessment
multiaxial system involves an assessment on several axes, each of which refers to a different domain of infomlation that may help th e clinician plan treatmen t and
predict outcome. The re are five axes included in the DSM IV multiaxial classification:
Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Axis II Personality Disorders Mental Retardation Axis m General Medical Cond itions Axis IV Psychosocial and Environmental Problems Axis V Global Assessment o f Functioning The use of the multiaxial system fa cilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical condi tions, psychosocial and environmental p roblems, and level of fun ctioning that might be overlooked if the focus were on assessing a single p resenting p roblem. A multiaxial system p rovides a convenient fomlat for organizing and communica ting clinical information, for capturing the complexity of clinical si tuations, and for describing the heterogeneity of in dividuals presenting w ith the same diagnosis. In addition, the multiaxial system promotes the application of the biopsychosocial m odel in clinical, educational. and research settings. The rest of this section provides a d escription of each of the OSM-IV axes. In some scttings o r situations, clinicians m ay prefer not to u se the multiaxial system. For this rcason, guidelines for reporting the results of a DSM-IV assessment without applying the formal multiaxial system are provid ed a t the end of this section.
Axis I
27
Multiaxial Assessment reason for visit w ill be assumed to be on Axis I unless the Axis II diagnosis is fo llowed by the qualifying phrase "(Principal Diagnosis)" or "(Reason for Visit)." U no Axis I disorder is present, this should be coded as V71 .09.lf an Axis I diagnosis is deferred, pending the gathering of additiona l information, this should be coded as 799.9.
Axis I Clinical Disorders Ot her Conditions That May Be a Focus of Clinical Attention
Disorde rs Usually First Diagnosed in Infancy, Ch ildhood, or Adolescence (excluding Mental Retardation, which is diagnosed on Axis II) Delirium, Dementia. and Amnestic and Other Cogn itive Disorders Mental Disorders Due to a General Medical Cond ition Substance-Related Disorders Schizophrenia and Other Psychotic Disorders Mood Disorders Anxiety Disord ers Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Impu lse-Control Disorders Not Elsewhere Classified Ad justment Diso rders Other Conditions That May Be a Focus of Clinica l Attention
Multiaxial Assessment order is present, this should be coded as V71.09. If an Axis II diagnosis is deferred, pend ing the gathering of additional infomlation, this should be coded as 799.9. Axis 11 may also be used to indica te prominent malad aptive personality features that do not meet the threshold for a Personality Disorder (in such instances, no code number should be used-see Example 3 on p. 37). The habitual use of maladaptive defense mechanisms may also be indicated on Axis 11 (see Appendix B, p. 811, for definitions and Example 1 on p. 37).
Multiaxi a l Assessment
In those instances in which the etiological relationship between the general medi-
ca l condition and the mental symptoms is insufficiently clear to warrant an Axis I diagnosis of Mental Diso rder Due to a General Medical Condition, the appropriate mental disorder (e.g., Major Depressive Disorder) shouJd be listed and coded on Axis I; the general m edical condition should only be coded on Axis ID. There are other situations in which general medical conditions are recorded on Axis LII because of their importance to the overall understanding or treatment of the individual with the mental disorder. An Axis I diso rder may be a psychological reaction to an Axis III general medical condition (e.g., the development of 309.0 Adjustment Disorder With Depressed Mood as a reaction to the d iagnosis of carcinoma of the brea st). Some general medical conditions may not be directly related to the ment.ll disorder but nonetheless have important prognostic o r treatment implica tions (e.g., when the diagnosis on Axis I is 296.30 Major Depressi ve Disorder, Recu rrent, and on Axis m is 427.9 arrhythmia , the choice o f pharmacotherapy is influenced by the general medical condition; or when a person with diabetes mellitus is admitted to the hospital for an exacerba tion of Schizophrenia and insulin management must be monitored). When an indiv idual has mo re than one clinically relevant Axis III diagnosiS, all should be reported. For examples, see p. 35. If no Axis UI disorder is present, this should be indicated by the notation "Axis ill: None. " If an Axis ill diagnOSis is deferred , pending the ga thering of additional information, this should be ind ica ted by the notation "Axis III Deferred ."
Axis III
General Medical Conditions (with ICO-9-CM codes) Infectiou s and Parasiti c Diseases (001- 139) Neoplasms (140-239) Endocrine, Nutritional, and Metabolic Diseases a nd Immu nity Di sorders
(24G-279)
Diseases of the Blood and Bl ood-Forming Organs (280-289) Diseases of the Nervous Syste m and Sense Org ans (320-389) Diseases of t he Circulatory Syste m (390--459) Diseases of the Respiratory System (460-51 9) Diseases o f the Digestive Syste m (520- 579) Diseases of the Genitourinary System (S80-629) Complica ti ons of Pregnancy, Childbirth, a nd t he Pu erperium (630-676) Diseases o f the Skin and Subcutaneous Tissue (680-709) Diseases o f the Musculo ske leta l System and Connective Tissue (7 10-739) Conge n ita l Ano malies (740-759) Certain Conditions Ori ginating in the Perinata l Period (760-779) Symptoms, Signs, and til-De fined Conditions (780-799) Inj u ry and Poisoning (800-999)
Multiaxia l Assessment
31
diagnosis, treatment, and prognosis o f mental disorders (Axes I and II). A psychosocial or environmental problem may be a negative life event, an environmental diffi culty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or personal resources, or other problem relating to the context in which a person's difficulties have developed . So-called positive stressors, such as job promotion, should be listed only if they con stitute or lead to a problem, as w hen a person has d ifficulty adapting to the new situation. In addition to p laying a role in the initiation or exacerbation of a mental disord er, psychosocial problems may also d evelop as a consequence of a person's psychopathology or may constitute prob lems that should be considered in the overall management plan. When an individual has multiple psychosocial or environmenta l p roblems, the clinician may note as many as are judged to be relevant. In general, the clinician should note only those psychosocial and environmental problems that have been presen t during the year preceding the cu rrent evaluation. However, the cl inician may choose to note psychosocial and environm ental p roblems occurring p rio r to the previou s year if these clearly contribute to the men tal disorder or have become a focus of treatment-for example, previous combat experiences leading to Posttraumatic Stress Disorder. In practice, most p sychosocial and environmental problems w ill be indicated on Axis tV. However, when a p sychosocial or environmental p roblem is the p rimary focus of clinical attention, it should also be recorded on Axis I, with a code derived from the section "Other Conditions That May Be a Focus of Clinical Attention" (see p. 731). For convenience, the problems are grouped together in the follow in g categories: Probl ems with primary support group e.g., death of a family member; health problems in famil y; disrup tion of family by separation , d ivorce, or estrangement; removal fro m the home; remarriage of p arent; sexual or physical abuse; parental overprotection; neglect of child; inad equate discipline; discord with siblings; birth of a Sibling Problems rel ated to the soci al env ironment--e.g ., death or loss of fri end; inad equate social support; living alone; difficulty with acculturation; d iscrimination; adjustment to life-cycle transition (such as retiremen t) Educational problems--e.g., illiteracy; academic prob lems; discord with teachers or classmates; inadequate school environment Occupational problems--e.g., unemployment; threat of job loss; stressful work schedule; difficult work conditions; job dissatisfa ction; job change; d iscord with boss or co-workers Hous ing problems--e.g., homelessness; inadequate housing; W1Safe neighborhood; discord with neighbors or landlord Economi c problems--e.g., extreme poverty; inadeq uate finances; insufficient welfare support Problems with access to health care services--e.g ., inad equate health care services; trans portation to health care fa cilities unavailable; inadequa te heal th insurance
~
32
Multiaxia l Assessment
Problems related to interaction with the lega l sys tem/crim e ceration; litigation; victim of crime
Axis IV
Multiaxial Assessment
that in situations where the individual's symptom se\'erity and level of functioning are discordant, the final GAF rating always reflects the worse of the two. For example, the GAF rating for an individual who is a significant d anger to self but is otherwise functioning well would be below 20. Similarly, the GAF rating for an individual with minimal psychological symptomatology but significant impairment in functioning (e.g., an individual whose excessive preoccupation with substance use has resulted in loss of job and friends but no other psychopathology) would be 40 or lower. In most instances, ratings on the GAF Scale should be for the current period (i.e., the level of functioning at the time o f the evaluation) because ratings of current fun ctioning will generally reflect the need for treatment or care. In order to account for dayto-day variability in functioning, the GAF rating for the "current period" is sometimes operationalized as the lowest level of functioning for the past week. In some settings, it may be useful to note the GAF Scale rating both at time of admission and at time of discharge. The GAF Scale may also be rated for other time periods (e.g., the highest level of functioning for at least a few months during the past year). The GAF Scale is reported on Axis V as follows: "GAF = ," foll owed by the GAF rating from a to 100, followed by the time period reflected by the rating in parentheses-for example, "(current)," "Chighest level in past year)," "(at discharge)." (See examples on p. 35.) In order to ensure that no elements of the GAF scale are overlooked when a GAF rating is being made, the following method for determining a GAF ra ting may be applied: STEP 1: Starting at the top level, evaluate each range by asking "is either the individual's symptom severity OR level of functiOning worse than what is indicated in the range description?" STEP 2: Keep moving down the scale until the range that best matches the individual's symptom severity OR the level of fun ctioning is reached, w hicheve r is worse. STEP 3: Look at the next lower range as a double-check against having stopped prematurely. This range should be too severe on bo th symptom severity and le\'el of functioning. If it is, the appropriate range has been reached (continue with step 4). If not, go back to step 2 and continue moving down the scale. STEP 4: To determine the specific GAF rating within the selected lO-point range, consider whether the individual is functioningat the higher or lower end of the topoint range. For example, consider an individual who hears voices that do not influence his behavior (e.g., someone w ith long-standing Schizoph.renia who accepts his hallucinations as part of his illness) . If the voices occur relatively infrequently (once a week or less), a ra ting of 39 or 40 might be most appropriate. In contrast, if the individual hears voices almost continuously, a rating of 31 or 32 would be more appropriate.
In some settings, it may be useful to assess social and occupational disability and to track progress in rehabilitation independent of the severity of the psychological symptoms. For this purpose, a proposed Social and Occupational Functioning Assessment Scale (SOFAS) (see p. 817) is included in Appendix B. Two additional pro-posed scales that may be useful in some settings-the Global Assessment of Relational Functioning (GARF) Scale (see p. 814) and the Defensive Functioning Scale (see p. B07)-are also included in Appendix B.
Multiaxial Assessment
100 Superior functioning in a wide range of activities, lif.'s problems never seem to I get out of h a nd, Is sought out by others because of his or her many positive qual 91 ities. No symptoms. 90
I
81
Absent or minimal s ymptoms (e.g., mild anxiety before an exam). good functioning in all areas, int.!' rested and involved in a wide range of activities. socially eHec tive, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family membe rs).
80 If symptoms are present, they are transient and expectable reactions to psychoI social stressors (e.g., difficulty concentrating after fam ily argument); no more than 71 slight Impairment in social, occupational, or school functioning (e.g., tempora rily falling behind in schoolwork). 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some diHiculty in I social, occupational, or school functioning (e.g., occasional truancy, or theft within the 61 household), but generally functioning pretty well, has some meaningful interper sonal relationsh ips. 60
I
51
Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate diH iculty in socia l, occupational, or school functioning (e.g., few friends, conflicts with peers o r coworkers).
50 Serious symptoms (e.g., suicidal ideation, severe obsessional ritua ls, frequent shoplifting) I OR a ny serious impairment in social. occupational, or school functioning (e.g., no 4 I fr iends, unable to keep a job). 40 Some impairment in reality testing or communication (e.g., speech is at times iIIogi I cal, obscure, or irrelevant) OR major impairment in severa l areas, such as work or 31 s chool, family re lations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 30 21 20
Behavior is considerably influenced by delusions or h a llucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, am grossly inappropriately, suicidal preoccupation) OR in"bility to function in almost all areas (e.g., stays in bed all d ay; no job, home, or friends). Some danger of hurting self or others (e.g., suicide attempU without clear expectation of death; frequently violent; manic excitement) OR octaslonally falls to ma intain min Imal personal h ygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
I
1I
10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR per I sistent Inability to maintain m inimal person,,1 hygiene OR serious suicidal act 1 with clear upectation of death. o Inadequate information. The rating of overall psychological functioning on a scale of 0-100 was operationalized by Luborsky in the Health-SickneS5 Rating Scale (Luborsky l : "Clinicians' Judgments of Mental Health." Archives of General Psychiatry 7:407-4 I 7, 1962). Spitzer and colleagues d eveloped a revision of t he Health Sickness Rating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer Rt, Fleiss Jt, Cohen J: "The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Distur bance." Archives of General ~chiatry 33:766-771, 1976). A modified version of the GAS was indud ed in D5M-II!R as the Global Assessment of Functioning (G AF) Scale.
Multiaxial Assessment
Axis I
M ajo r Depressive Disorde r, Single Episode, Severe Without Psychotic Features 305.00 Alcohol Abuse 301.6 Dependent Personality Disorder Frequent use of denial None Threat of job loss GAF = 35 (current)
296 .23
Dysthymic Disorder Read ing Disorder No diagnosis 382.9 Otitis media. recurrent Victim of child neglect GAF = 53 (current)
Example 3:
Mood Disorder Due to Hypothyroid ism. W ith Depressive Feat ures V7 1.09 No d iagnosis, histrionic personality features 244.9 Hypothyroidism 365.23 Chronic angle-closure glaucoma None GA F = 45 (on admission) GA F = 65 (at discharge)
293.83
Example 4:
V6 1.10 V7 1.09
Partner Relational Problem No diagnosis None Unemployment GAF = 83 (highest level past year)
36
AXIS I:
Diagnostic code
---'----"-- - -'-
AXIS II:
Personality Disorders
Mental Retardation
Diagnostic code
---"----"--
DSM-IV name
ICO-9-CM name
Problems with primary support group Speci fy: _ _ _ _ _ _ _ __ Problems related to the socilll e n v ironment Speci fy: _ _ _ _ __ _
Q Q
Q
a a
AXIS V:
Multiaxial Assessment
37
Nonaxial Format
Clinicians who do not wish to u se the multiaxial format may simply list the appropri ate diagnoses. Those choosing this option should follow the genera l rule of recording as many coexisting mental disorders, general medical conditions, and other factors as are relevant to the care and treatment o f the individuaL The Principal Diagnosis or the Reason for Visit should be listed first. The examples below illustrate the reporting of diagnoses in a format that does not use the multiaxial system.
Example 7: 296.23 Majo r Depressive Disorder, Single Episode, Severe Without Psychotic Features 305.00 Alco hol Abuse 301.6 Dependent Personality Disorder; Frequent use of denial Example 2: 300.4 Dysthymic Disorder 315.00 Reading Disorder 382.9 Otit is med ia, recurrent Example 3: 293 .83 Mood Diso rder Due to Hypothyroidism, With Depressive Features 244.9 Hypothyroidism 365.23 Chronic angleclosure glaucoma Histrionic personality featu res Example 4: V61.10 Partner Relational Problem
T he provision of a separate section for disorders that are usually first d iagnosed in infancy, childhood, o r adolescence is for convenience only and is not meant to suggest that there is any clear dis tinction between "childhood " and "adult" disorders.
Although most individuals with these d isorders present for clinical attention during childhood or adolescence. the disorders sometimes are not diagnosed until adulthood. Moreover, many disorders included in other sections of the manual oft en have
an onset during childhood or adolescence. In evaluating an infant, child , or adolescent, the clinician s hould consider the diagnoses included in this section but also should refer to the disorders described elsewhere in Ih is manual. Adults may also be diagnosed with disord ers included in this section for Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence if their clinical p resentation meets relevant diagnostic criteria (e.g ., Stuttering, Pica). Moreover, if an adult had symptoms as a child that met full criteria for a d isorder, but now presents w ith an attenuated or residual fonn, the In Partial Remission specifier may be indicated (e.g., AttentionDeficit / Hyperactivity Disorder, Combined Type, In Partial Remi ssion). For most (bu t not all) DSM-TV disorders, a single criteria set is provided that applies to children, adolescents, and adults (e.g., if a child or ado lescent has symptoms that meet the criteria for Major Depressive Disorder, this d iagnosis should be given, regardJess of the individ ual's age). The variations in the presentation of a disorder that are attribu table to an individual's d e\'elopmental stage are d escribed in a section in the text titled "Specific Culture, Age, and Gender Features." Specific issues related to the diagnosis of Personality Disorders in children or adolescen ts are disG;lssed on p. 687. The fon owing disorders are included in this section:
Mental Retardation. This disorder is characterized by significantly subaverage intellectual functioning (an IQ of approximately 70 or below) with onset before age 18 years and concurrent d efi cits or impa imlents in adaptive functioning. 5eparatecodes are provided for Mild, Moderate, Severe, and Profound Men tal Retardation and for Mental Retardation, Severi ty Unspecified. Learning Disorders. These disorders are characterized by academic functioning that is substantially below that expected given the person's chronologica l age, measured intelligence, and age-appropriate education. The specific disorders included in this section are Reading Disorder, Math em atics Disorder, Disorder of Written Expression, and Learning Disorder Not O therw ise Specified.
39
Motor Skills Disorder. This includes Developmental Coordination Disorder, which is characterized by m otor coordination that is substantially below that expected given the person's chronological age and measured intelligence. Communication Disorders. These disorders are characterized by difficulties in s peech or language and include Expressive Language Disorder, Mixed ReceptiveExpressive Language Disorder, Phonological Disorder, Stu ttering, and Communication Disorder Not Othenvise Specified. Pervasive Developmental Disorders. These disorders are characterized by severe deficits and pen'asive impairment in multiple areas of development. These include impairment in reciprocal social interaction, impairment in communication, and the presence of stereotyped behavior, interests, and activ ities. The specific disorders included in this section are Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder, and Pervasive Developmental D isorder Not Othenvise Specified. Attention-Deficit and Disruptive Behavior Disorders. This section includes Attention-DeficitlHyp eractivHy Disorder, wh ich is characterized by prominent symptoms of inattention and / or hyperactivity -impulsivity. Subtypes are provided for s pecifying the predominant symptom presentation: Predominantly Inattentive Type, Predominan tly Hyperadive-lmpulsive Type, and Combined Type. Also included in this section are the Di sruptive Behavior Disorders: Conduct Disorder is characterized by a pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules; Oppositional Defiant Disorder is characterized by a pattern of negativistic, hostile, and defiant behavior. This section also includes h vo Not Othenvise Specified categories: Attention-DeficitIHyp eractivity Disorder Not Othenvise Specified and Disruptive Behavio r Disorder Not Otherwise Specified . Feeding and Eating Disorders of Infan cy or Early Child h ood . These disorders are characterized by persistent disturbances in feeding and eating. The specific disorders included are Pica, Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood . Note that Anorexia Nervosa and Bulimia Nervosa are included in the "Eating Disorders" section presen ted later in the manual (see p. 583). Tic Disorders. These disorders are characterized by vocal and / or motor tics. The specific disorders includ ed are Tourette's Disorder, Chronic Motoror Vocal Tic Disorder, T ransien t Ti c Disorder, and Tic Disorder No t Othenvise Specified. Eliminati on Disorders. This grouping includes Encopresis, the repeated passage of feces into inappropriate p laces, and Enuresis, the repeated voiding of urine into inappropriate places. Other Disorders of Infancy, Childhood, or Adolescence. This grouping is for disorders that are not covered in the sections listed above. Separation Anxiety Disorder is characterized by developmentally inappropriate and excessive anxiety concerning
Mental Retardation
separation from home or from those to whom the child is attached . Selective Mutism is characterized by a cons is tent failure to speak in specific social situations despite speaking in other situations. Reactive Attachment Disorder of lnfancy or Early Childhood is characterized by markedly disturbed and developmentally inappropriate social relatedness that occurs in m ost contexts and is associa ted with grossly pathogenic care. Stereotypic Movement Disorder is characterized by repetitive, seemingly driven, and nonfunctional motor behavior that markedly interferes w ith norm al activities and at times may result in bodily injury. Disorder of Infancy, Childh ood, or Ado lescence Not Othenvise Specified is a residual category for coding disorders with onset in infancy, childhood, or adolescence that do not meet criteria for any specific disorder in the Classification. Children or adolescents may present with problems requiring clinical attention that are not defined as mental disorders (e.g., Relational Problems, Problems Related to Abuse or Neg lect, Bereavement, Borderline Intellectual Functioning, Acad emic Problem, Child or Adolescent Antisocial Behavio r, Identity Problem). These are lis ted. at the end of the manual in the section "Other Conditions That May Be a Focus of Clinical Attention" (see p . 731). DSM-ill-R included two anxiety disorders specific to chiJdren and adolescents, Overanxious Disorder of Childhood and Avoidant Disorder o f C hildhood, that have been s ubsumed under Generalized Anxiety Disorder and SociaJ Phobia, respectively, because of similarities in essential features.
Mental Retardation
Diagnostic Features
The essential feature of Mental Retardation is significantly s ubaverage general intellectual functioning (Criterion A) that is accompanied by significant limitations in adaptive fu nctioning in at least two of the following skill areas: communication, self-care, home living, SOCial/ interpersonal s kills, use of community resources, self-direction, , functional academic skills, work, leisure, health, and sa"fety (Criterion B). The onset must occur before age 18 years (Criterion C). Mental Retardation has many d ifferent etiologies and may be seen as a fina l common pathway of various patholOgical processes that affect the functioning of the centraJ nervous system . Gelleral ill tel/eetllal fimetialli1lg is defin ed by the intell igence quotient (IQ o r IQequivalent) obtained by assessment with one or more of the s tandardized, individually adminis tered intelligence tes ts (e.g., Wech sler intelligence ScaJes for Children, 3rd Edition; Stanford-Binet, 4th Edition; Kaufman Assessment Battery for Child ren). Significantly subaverage inteUectual functioning is defined as an IQ of about 70 or below (approximately 2 standard d eviations below the m ean). It should be noted that there is a m easurement error of approxim ately 5 p oints in assessing IQ although this may vary from instrument to instrument (e.g., a Wechs ler IQ of 70 is cons idered to represent a range of 65-75). Thus, it is possible to diagnose Mental Retardation in
42
individuals with IQs between 70 and 75 w ho exhibit significant defici ts in adaptive behavior. Conversely, Mental Retardation would not be diagnosed in an individual w ith an IQ lower than 70 if there are no significant defici ts or impairments in adaptive function ing. The choice of testing instruments and interpreta tion of results should take into account fac tors tha t may limit test performance (e.g ., the individual's sociocultural backg rmmd, native language, and associated communicative, motor, and sensory handicaps). When there is significant scatter in the subtest scores, the profile of strengths and weaknesses, rather than the mathematically derived full-scale IQ w ill more accurately reflect the person's learning abilities. ' '''hen there is a marked discrepancy across verbal and performance scores, averaging to obtain a hill-scale IQ score can be misleading. impairments in adaptive functioning, rather than a low IQ, are usually the presenting symptoms in individuals with Mental Retardation. Adaptive fll nctionillg refers to how effectively individuals cope w ith corrunon life demands and how well they meet the standards of personal independence expected of someone in their particular age group, sociocultural background, and corrununity setting. Adaptive functioning may be influenced by various fac tors, including education, m otivation, personality characteristics, social and vocational opportuniti es, and the mental disorders and general medical conditions that may coexist with Mental Retardation. Problems in adaptation are more likely to improve with remedial efforts than is the cognitive lQ which tends to remain a more s table a ttribute. It is useful to gather evidence for deficits in adaptive ftmc tioning from one or morc reliable independent sources (e.g., teacher eva luation and educational, developmental, and medical h istory). Several scales have also been designed to measure adapti ve functioning or behavior (e.g., the Vineland Adapti ve Behavior Sca les and the America n Association on Mental Retardation Adaptive Behavior Sca le). These scales generaUy provide a clinical cutoff score that is a comp osite of performance in a number of adaptive s kill domains. It should be noted that scores for certain indiv idual domains are not induded in some of these ins truments and that individual domain scores may vary considerably in reliabi lity. As in the assessment of intellectual hmctioning, consideration s hould be given to the suitability of the instrument to the person's sociocultural background, education, associated handicaps, motivation, and cooperation. For instance, the presence of significant handicaps invalidates many adaptive scale norms. In addition, beha\'iors tha t would normally be considered maladaptive (e.g., dependency, passivity) may be evidence of good adaptation in the context of a particular individual's life (e.g., in some institutional settings).
317
319 Mental Retardation, Severity Unspecified, can be used when there is a strong presumption of Men tal Retardation but the person 's intelligence is untes table by standard tesls (e.g., with individua ls too impaired or uncoopera ti ve, or with infan ts).
317
Mild Mental Retardation is roughly equi valent to what used to be referred to as the educational category of "educable." This group constitutes the largest segment (about 85%) of those with the disorder. As a group, people w ith this level of Mental Retardation typically develop social and communica tion s kills during the preschool years (ages O-S years), h ave minimal impairment in sensorimotor areas, and often are not d is tinguishable from children without Mental Retardation until a later age. By their late teens, they can acquire academic skills up to approximately the sixth-grade level . During their ad ult years, they u sually achieve social and vocational skills adequate fo r minimum self-support, but may need supervision, guidan ce, and assist.lOce, especially when under u nusual social or economic stress. '''lith appropriate supports, individuals with Mild Men l.)l Retardation can usually live s uccessfully in the conuntmity, either independently or in s upervised settings.
318.0
Moderate Mental Retardation is roughly equ ivalent to what used to be referred to as the educational category of "trainable." This outdated tenn should not be used because it wrongly implies that people with Moderate Mental Retardation cannot benefit from educational programs. This group constitu tes about 10% of the entire population of people w ilh Mental Retardation. Mos t of the individuals w ith this level of Menial Retardation acquire communication skills during early childhood years. They profit from vocational training and, wi th moderate supervision, can atten d to their personal care. They can also benefit from training in social and occupational skills but are unlikely to progress beyond the second-grade level in academic subjects. They may leam to travel independently in familiar p laces. During adolescence, their d ifficulties in recognizing social conventions may interfere with peer relationships. In their adult years, the majority are able to perfom1 unskilled or semiskilled work lmder supervision in sheltered workshops or in the general workforce. They adapt well to life in the conununity, usually in supervised settings.
~
318.1
The group with Severe Mental Retardation constitutes 3%-4 % of individuals wi th Mental Retardation. During the early childh ood years, they acquire little or no communicative speech. During the school-age period, they may learn to talk and can be trained in elemen tary self-ca re skills. They profit to only a limited extent from instruction in pre-academic s ubjects, such as familiarity with the alphabet and simple counting, but can master skills sudl as learning sight reading of some "surviva l" words. In their adult years, they may be able to perform simple tasks in closely supervised set-
Childhood, or Adolescence tings. Most adapt well to life in the community, in group homes or with their families, unless they have an associated handicap that requires spedalized nursing o r other care.
318.2
The group with ProfOlmd Mental Retardation constitu tes approximately 1%-2% of people with Mental Retardation. Most individuals with this diagnosis have an identified neurologica l condition that accounts for their Menta l Retardation. During the early childhood yea rs, they display consider.lble impainnents in sensorimotor functioning. Optimal development may occur in a highly structured environment with constant aid and supervision and an individualized relationship with a caregiver. Motor development and self-care and communication skills may improve if appropriate training is provided . Some can perform simple tasks in closely supervised and sheltered settings.
319
The diagnosis of Mental Retardation, Severi ty Unspecified, should be used when there is a strong presumption of Menta l Retardation but the person carUlot be successfully tested by standardized intelligence tests. This may be the case when children. adolescents, or adults are too impaired or uncooperative to be tested or, with infants, when there is a clinica l judgment of signifi cantly subaverage intellectual functioning. but the available tests (e.g., the Bayley Scales of Infant Development, Ca ttell Infant Intelligence Scales, and others) do not yield lQ values. In general, the you nger the age, the more difficult it is to assess for the presence of Mental Retardation except in those with profound impairment.
Recording Procedures
The specific d iagnostic code for Mental Retardation is selected based on the level of severity as indicated above and is coded on Axis U. If Mental Retarda tion is associated with another mental disorder (e.g., Autistic Disorder), the additional mental disorder is coded on Axis r. If Mental Retardation is associated with a general medical condition (e.g., Down syndrome), the general medical condition is coded on Axis m.
Mental Retardation
vulnerable to exploitation by others (e.g., being physically and sexually abused ) or being denied rights and opportunities. Individuals with Mental Retardation have a prevalence of comorbid mental disorders that is estimated to be three to four times greater than in the general population. In some cases, this may result from a shared etiology that is common to Mental Retardation and the associated mental disorder (e.g., head trauma may result in Mental Retardation and in Personality Change Due to Head Trauma). All types of mental disorders may be seen, and there is no evidence that the nature of a given mental disorder is different in individuals who have Mental Retardation. The diagnosis of comorbid mental disorders is, however, often complicated by the fact that the clinical presentation may be modified by the severity of the Mental Retardation and associated handicaps. Deficits in communication skills may resuit in an inability to provide an adequate history (e.g., the d iagnosis of Major Depressive Disorder in a nonverbal adult wi th Mental Retardation is often based primarily on manifestations such as depressed mood, irritability, anorexia, or insomnia that are observed by others). More often than is the case in individuals without Mental Retardation, it may be difficult to choose a specific diagnosis and in such cases the appropriate lot Othem<jse Specifi ed category can be used (e.g., Depressive Disorder Not Otherwise Specified). The most common assodated mental disorders are Attention-Deficit / Hyperactivity Disorder, Mood. Disorders, Pervasive Developmental Disorders, Stereotypic Movement Disorder, and Mental Disorders Due to a General Medical Condition (e.g., Dementia Due to Head Trauma). Individuals who have Mental Retardation due to Down syndrome may be at higher risk for developing Dementia of the Alzheimer's Type. Pathological changes in the brain associated \\<jth this disorder usually develop by the time these individuals are in their early 4Os, although the clinical sym ptoms of dementia are not evident unti1 later. Associations have been reported between sp ecific etiological factors and certain comorbid symptoms and mental disorders. For example, fragil e X syndrome appea rs to increase the risk for Attention-Defi cit / H yperactivity Disorder and Social Phobia; individuals with Prader-Willi syndrome may exhibit hy perphagia and compulsivity, and those w ith William's syndrome may have an increased risk of Anxiety Disorders and A ttention-Deficit / H yperactivity Disorder.
Predisposing factors. Etiological fa ctors may be primarily biological or primarily psychosocial, or some combination of both. In a pproximately 30%--40% of individuals seen in clinical settings, no clear etiology for the Mental Retardation can be determined despite exten sive "valuation efforts. Specific etiologies are more likely to be identified in individuals with Severe or Profound Mental Retardation. The major predisposing fa ctors include:
Prevale nce
The prevalence rate of Mental Retardation has been estimated a t approximately 1"10. However, different studies have reported different rates depending on d efinitions used, methods of ascertainment, and p opulation studied.
Mental Retardation
47
Course
The diagnosis of Mental Retardation requires that the onset of the disorder be before age 18 years. The age and mode of onset depend on the etiology and severity of the Mental Retardation. More severe retardation, especially when associated with a syndrome w ith a dlaracteristic phenotype, tends to be recognized early (e.g., Down syndrome is usually diagnosed at birth). In contrast, Mild Retardation of unknown origin is generally noticed later. In more severe retardation resulting from an acquired cause, the intellectual impairment will d evelop more abruptl y (e.g., retard ation following an encephalitis). The course o f Mental Retardation is influenced b y the course of underlying general medical conditions and by environmental fa ctors (e .g., educational and other opportunities, environmental s timulation, and appropriateness of management). lf an illIderlying general medical condition is static, the course is more likely to be variable and to depend on environmental fac tors. Mental Retardation is not necessarily a lifelong disorder.lndividua ls who had Mild Mental Retard ation earlier in their lives manifested by failure in academic learning tasks may, w ith appropriate training and opportunities, d evelop good adaptive skills in other domains and may no longer have the level of impairment required for a diagnosis of Mental Retardation.
Familial Pattern
Because o f its heterogeneous etiology, no familial pattern is applicable to Mental Retardation as a general category . The heritability of Mental Retardation is d iscussed under "Predisposing Factors" (see p. 45).
Differentia l Diagnosis
The diagnos tic criteria for Mental Retardation do not include an exclusion criterion; therefore, the diagnosis should be made whenever the diagnostic criteria are met, regardless of and in addition to the presence of another disorder. In learning Disorders or Communication Disorders (unassociated with Mental Retardation), the development in a s pecific area (e.g., reading, expressive language) is impaired but there is no generalized impainnent in intellectua l d evelopment and adaptive functioning. A Learning Disorder or Communication Disorder can be diagnosed in an individual w ith Mental Retardation if the specific deficit is out of proportion to the severity of the Mental Retardation . In Pervasive Developmental Disorders, there is qualitative impairment in the development of reciprocal social interaction and in the development of verbal and nonverbal social communication skills. Mental Retardation often accompanies Pervasive Developmental Disorders. Some cases of Mental Retardation have their o nset after a period of normal fun ctioning and may qualify for the additional diagnosis of dementia. A d iagnosis of d ementia requires that the memory impairment and other cognitive d efi cits represent a significant decline from a previou sly higher level of functioning . Becallse it may be difficult to determine the previoll s level of fWlCtioning in very yOilllg children, the diagnosis o f dementia may not be appropriate lUltil the child is between ages 4 and 6 years. In general, for individuals tmder age 18 years, the diagnosis of dementia is
48
made only w hen the condition is not characterized satisfactorily by the diagnosis of Mental Retardation alone. Borderline Intellectual Functioning (see p. 740) describes an IQ range that is higher than that for Mental Retardation (generally 71--84) . As discussed earlier, an IQ score may involve a measurement error of approximately 5 points, depending on the testing instrument. Thus, it is possible to diagnose Mental Retardation in individuals with IQ scores between 71 and 75 if they have significant deficits in adaptive behavior that meet the criteria for Mental Retardation. Differentiating Mild Mental Retardation from Borderline Intellectual Flmctioning requires careful considera tion of all available information.
49
0 on an individually admin istered 1 test (for infants, a clinical judgment of significantly subaverage intel lectua l funct ioning) . B. Concurrent deficits or impairments in present adaptive functioning (i .e., the person's effectiveness in meeting the standards expected for his or her age by his or her cu[tura l group) in at least two of the fo ll owing areas: comm unicat ion, self-ca re, home living, socialfinterpersonal skills, use of community resources, self-direction, functiona l aca demic sk ills, work, leisure, health, and safety.
C. The onset is before age 18 years.
Mild Mental Retardation: 10 level 50--55 to approximately 70 Moderate Mental Retardation: 10 level 35-40 to 50--55 Severe Mental Retardation: 1 level 20--25 to 35-40 0 Profound Mental Retardation: 1 level below 20 or 25 0 Mental Retardation, Severity Unspecified: whe n there is strong presumption of Mental Retardation but the person's intell igence is untestable by standard t ests
The section on Learning Disorders includes Reading Disorder, Mathematics Disorder, Disorder of Written Expression, and Learning Disorder Not Otherwise Specified.
15 0
present. the learning difficulties must be in excess of those usually associated with the deficit. Learning Disorders may persist into adulthood.
Prevalence
Estim ates of the prevalence of Leaming Disorders range from 2% to 10% depending on the nature of ascertainment and the definitions applied . Approximately 5"/0 of students in public schools in the United States are identified as h aving a Learning Disorder.
315.00
315.00
Diagn ostic Features
Reading Disorder
The essential feature of Reading Disorder is reading ach ievement (i.e., reading accuracy, speed, or comprehension as measured by individua lly adminis tered s tandardized tests) that falls subs tantia lly below that expected given the individual's chronolOgical age, measured intelligence, and age-appropriate education (Criterion A). The dis turbance in reading signi fican tly interferes w ith academ ic achievement or with activities of daily living that req uire reading s kills (Criterion B). If a sensory deficit is presen t, the reading difficulties are in excess of those us ually associated with it (Criterion C). If a neurological or other general medical condition or sensory d eficit is present, it should be coded on Axis HI. In individuals with Reading Disorder (which
52
has also been called "d yslexia"), oraJ reading is characteri zed by dis tortions, substitutions, or omissions; bo th oral and silent reading are characterized by slowness and errors in comprehension.
Preva lence
The prevalence of Readin g Disorder is difficult to establish because many s tudies focus on the prevalence o f Leaming Disorders without careful separation into specific disorders of Reading, Mathematics, o r Written Expression . Reading Disorder, alone or in combination with Mathematics Disorder or Disorder of W ritten Expression, accounts for approximately four of every fi ve cases o f Leanting Disorder. The prevalence of Reading Disorder in the Uni ted States is estimated at 4% of school-age children. Lower incidence and prevalence figures for Readi ng Disorder may be found in other countries in which s tricter criteria are used.
Course
Although sympto ms of reading difficulty (e.g., inab ility to dis tinguish among common letters or to associa te common phonemes with letter symbols) may occur a;; early as kindergarten, Reading Disorder is seldom d iagnosed before the end of kindergarten or the beginning of first g rade because formal reading ins truction usually does no t begin until this poin t in m ost school settings. Particula rly when Reading Disorder is associated with high IQ. the child may function at or near g rade level in the early grades, and the Reading Disorder may not be fully apparent until the fourth grade or later. With early identification and inten'ention, the prognosis is good in a significan t p ercentage o f cases. Readin g Disorder may persis t into adult life.
Familial Pattern
Read ing Disorder aggregates familially and is more p revalent among firs t-degree biological relatives of individuals with Learning Disorders.
315.1
Mathematics Disorder
Differential Diagnosis
See the "Differential Diagnosis" section for Learning Disorders (p. 51) .
sociated with it. Coding note: If a general med ical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.
315.1
Diagnostic Features
Mathematics Disorder
The essential feature of Mathematics Disorder is mathematical ability (as measured by individually administered standardized tests of mathematical calculation or reasoning) that falls subs tantially below that expected for the individual's c1uonological age, measured intelligence, and age-appropriate education (Criterion A). The disturbance in mathematics Significantly interferes with academic achievement or with activities of daily living that require mathematical skills (Criterion B). If a sensory deficit is present, the difficulties in mathematical ability are in excess of those u sually associated with it (Criterion C). If a neurological or other general medical condition or sensory deficit is present, it should be coded on Axis Ill. A number of different skills may be impaired in Mathematics Disorder, incJu..ding "linguistic" skills (e.g., understanding or naming mathematical terms, operations, or concepts, and decoding written problems into mathematical symbols), "perceptual" skills (e.g., recognizing or reading numerical symbols or arithmetic signs, and clustering objects into groups), "attention" s kills (e.g., copying numbers or figures correctly, remembering to add in "carried" numbers, and observing operational signs), and "mathematical" skills (e.g., following sequences of mathematical steps, counting objects, and learning multiplication tables).
Preva lence
The prevalence of Mathematics Disorder is difficult to establish because many studies focus on the p revalence of Leaming Disorders without careful separation into specific disorders of Reading, Mathematics, or Written Expression. The prevalence of Mathematics Disorder alone (Le., when not found in association with oUler Learning Disorders) has been estimated at approximately one in every five cases of Learning Disorder. It is estimated that 1% of school-age children have Mathematics Disorder.
Co u rse
Although symptoms of d ifficu lty in mathematics (e.g., conhlsion in number concepts or inability to count accurately) may appear as early as kindergarten or first grade, Mathematics Disorder is seld om diagnosed before the end of first grade because sufficient formal ma thematics instruction has usually not occurred un til this point in most school settings. It usually becomes apparent during second or third g rade. Particularly when Mathematics Disorder is associated with high IQ the child may be able to function at or near grade level in the early grades, and Mathematics Disorder may not be apparent until the fifth grade or later.
8. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematica l ability.
C. If a sensory deficit is present, t he difficult ies in mathematical ability are in excess of
those usually associated wit h it. Coding note: If a general medical (e.g., neurologica l) condition or sensory deficit is present, (Ode the condition on Axis III.
315.2
Diagnostic Features
The essential feature of Disorder of Written Expression is w riting skills (as measured by an ind ividually administered standardized test or functional assessment of writing skills) that fall substantia lly below those expected given the individual's chrono-
315.2
55
logical age, measured intelligence, and age-appropriate education (Criterion A) . The dis turbance in w ritten expression significantly interferes with academic achievement or with activities of daily living that require w riting skills (Criterion B). If a sensory deficit is present, the difficulties in writing skills are in excess of those us ualJy associated with it (Criterion C) . If a neurological or other general medical condition or sensory deficit is present, it shoul d be coded on Axis ill. There is generally a combination of difficulties in the individual's ability to compose written texts evidenced by grammatical or punctuation errors within sentences, poor paragraph organization, multiple spelling errors, and excessively poor handwriting. This diagnosis is generally not given if there are only s pelling errors or poor handwriting in the absence of other impai rment in written expression . Compared with other Learning Disorders, relatively less is known about Disorders of Written Expression and their remediation, particularly when they occur in the absence of Reading Di sorder. Excep t for spelling, standardized tests in this area are less well developed than tes ts of reading or mathematica l ability, and the evaluation of impairment in written skills may require a compari son beh\'een extensive samples of the individual's w ritten schoolwork and expected perfonnance for age and IQ. This is especially the case for young children in the early elementary grades. Tasks in which the child is asked to copy, write to dictation, and write s pontaneously may all be necessary to establish the presence and extent of this disorder.
Prevalence
The prevalence of Disorder of Written Expression is difficult to establish because many s tudies focus on the prevalence of Learning Disorders in general without careful separation into sp ecific Disorders of Reading, Ma thematics, or Written Expression. Disorder of Written Expression is rare when not associated with other Learning Disorders.
Cou rse
Although difficulty in writing (e.g., particularly poor handwriting or copying ability or inability to remember letter sequences in common words) may appear as early as the first grade, Disorder of Written Expression is seldom diagnosed before the end of first grade because sufficient fonnal writing instruction has u sually not occurred until this point in m ost school settings. The di sorder is u sually apparent by second grade. Disorder of Written Expression may occasionally be seen in old er children or adults, and li ttle is known about its long-term prognosi s.
56
Different ial Diagnosis
See the "Differential Diagnosis" section for Learning Disorders (p. 51). A disorder in spelling or handwriting alone, in the absence of other d ifficul ties of written expression. generally does not qualify for a diagnosis of Disorder of Written Expression. U poor handwriting is due to impairment in molor coordination, a diagnosis of Developmental Coordination D isorder s hould be considered.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that requ ire the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usu ally associ ated with it.
Coding note: If a general medical (e.g ., neurological) condition o r sensory deficit is present, code the condition on Axis III.
315.9
This ca tegory is for d isorders in learning that do not meet cri teria for any specific Learning Disorder. This category might include problems in all three areas (reading.. mathematics, written expression) that together significantly interfere with academ.ic achievement even though performance on tests measuring each individual skill is not substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
315.4
315.4 Developmental Coordination Disorder ties of daily living (Criterion B). The diagnosis is made if the coordination difficulties are not due to a general medical cond ition (e.g., cerebral palsy, hemiplegia, or muscular d ystrophy) and the cri teria are not met for Pervasive Developmental Disorder (Criterion C). If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it (Criterion D). The manifestations of this disorder vary with age and development. For example, younger children may display clumsiness and delays in achieving developmental motor milestones (e.g., walking, crawling, sitting, tying shoelaces, buttoning shirts, zipping pants). O ld er children may display difficulties with the m otor aspects of assembling puzzles, building models, playing baU and printing or handwriting. ,
Preva lence
Prevalence of Developmental Coordination Disorder has been estimated to be as high as 6% for children in the age range of 5-11 years.
Course
Recognition of Developmental Coordination Disorder usually occurs when the child firs t attempts such ta sks as running, holding a knife and fork, buttoning clothes, or playing ball games. The course is variable. ln some cases, lack of coordination continues through adolescence and adulthood.
Differential Diagnosis
Developmental Coordination Disorder must be distinguished from motor impairments that are due to a general medical condition. Problems in coordination may be associated with specific neurological disorders (e.g., cerebral palsy, progressive lesions of the cerebellum), but in these cases there is d efinite neural damage and abnormal findings on neurological examination. If Mental Retardation is present, Developmental Coordination Disord er can be diagnosed only if the m otor difficulties are in excess of those usually associated w ith the Menial Retardation. A diagnosis of Developmental Coordination Di sorder is not given if the criteria are met for a Pervasive Developmental Disorder. lndividuals w ith Attention-Deficit/Hyperactivity Disorder may fall , bump into things, o r knock things over, but this is usually due to distractibili ty and impulSiveness, rather than to a moto r impairment. U criteria for both d isorders are mel, both diagnoses can be given.
58
Childhood, o r Adolescence
C. The disturbance is not due t o a general medical condition (e.g ., cerebra l palsy. hemiplegia, o r muscular dystrophy) a nd does not meet criteria for a Pervasive Developme ntal Disorder.
D. If Mental Retardation is present, the motor difficulties are in excess of t hose associated with it.
usua l ~
Coding note: If a general medical (e.g., neu rolog ical) (Ondit ion or senmry deficit is present, (Ode the condition on Axis II I.
Communication Disorders
The foHowing Communication Disorders are inclu ded in this section: Expressive Language Disorder, Mixed Receptive-Expressive Lang uage Disorder, Phonologicdl D isorder, Stuttering, and Communication Disorder Not Othenvise Specified. The)' are included in this classification to familiarize clinicians w ith the ways in which Communication Disorders present and to facilitate their differen tial diagnosis.
315.31
Diagnostic Features
The essential feahueof Expressive Language Disorder is a n im paimlent in expressi\'e language development as demonstrated by scores on standardized individually ad minis tered measures of expressive language development s ubstantially below those obtained from s tandardized measures of both nonverbal intelJectual capacity and receptive language development (Criterion A) . When standardized instruments are nol availableor appropriate, the diagnosis may be based on a thorough hmctional assessment of the individual 's language ability. The difficulties may occur in conununicdtion involvi.ng both verbal language and sign language. The language difficulties interfere with academic or occupational ach ievement or w ith social communication (Criterion B). The symptoms do not meet criteria for Mixed Recepti ve-Expressire
315.31
59 \
language Disorder or a Pervasive Developmental Disorder (Criterion C). if l'vlental Retardation, a speech-motor or sensory deficit, or environmental depri vation is present, the language difficulties are in excess of those u sually associated with these problems (Criterion D). If a sp eech-motor or sensory deficit or neurological condition is present, it should be coded on Axis III. The linguis tic features of the disorder vary depending on its severity and the age of the child. These features include a limited amount of speech, limited range of vocabulary, difficulty acquiring new words, word-finding or vocab ulary errors, shortened sen tences, simplified g rammatical structmes, limited varieties of gramma tical structures (e.g ., verb fo rms), limited varieties of sentence types (e.g., imperatives, questions), omissions of critical parts of sentences, use of tulus ual word order, and slow rate of language developmen t. Nonlinguistic functioning (as measured by perfomlance intelligence tests) and language comprehension skills are usually within normal limits. Expressive Language Disorder may be either acquired or developmental . In the acqui red type, an impairment in expressive language occurs after a period of normal development as a result of a neurological or other general medical condition (e.g., encephalitis, head trauma, irradiation). In the developmental type, there is an impairment in expressive language that is not associa ted with a postna tal neurological insult of known origin. Child ren with this type often begin spea king late and progress more slowly than usual through the various s tages of expressive language development.
60
and of nonverbal intellectual cap acity must be relevan t for the cultural and lingu istic group (i.e., tests developed and standardized for one g roup may no t provide appropriate norm s for a different group). The developmental type of Expressive Language Disorder is more common in males than in females.
Prevalence
Prevalence estimates va ry with age. In children under 3, language delays are quite common, occurring in 100/ .-15% of children. By school age, prevalence estimates . range from 3% to 7%. The developmental type of Expressive Language Disorder is more common than the acquired type.
Co urse
The d evelopmental type o f Expressive Lang uage Disorder is usually recognized by age 3 years, although milder forms of the d isorder may not become apparent until early adolescence, when language ordinarily becomes more complex. The acquired type of Expressive Language Disorder due to brain lesions, head trauma, or stroke may occur at any age, and the onset is sudden. The outcome o f the developmental type of Expressive Language Disorder is variable. A majority of children with this d isorder improve substantially; in a smaller proportion, d iffi culties persist into adulthood. Most children ultimately acqu ire more o r less normal language abilities by late ad olescence, although subtle deficits may persist. In the acquired type of ExpressinLanguage Disorder, the course and prognosis are related to the severi ty and location of brain pathology, as well as to the age of the child and the extent o f language development at the time the d isorder is acquired. Clinical improvement in language abilities is sometimes rapid and com plete, although d efici ts in communication and related cogniti ve abilities may persist. In other instances there may be progressive d eficit.
Familial Pattern
It appears that thedevelopmental type of Expressive Language Disorder is more likely to occur in individ ua ls w ho have a family history of Commlmication or Learning Disorders. There is no evidence o f familial aggregation in the acqUired type.
Differential Diagnosis
Expressive Lang uage Disorder is distinguished from Mixed Receptive-Exp ressive Language Disorder by the presence in the la tter of significant impairment in recepti ve language; many ind ividuals w ith Expressive Language Disorder have subtledif ficulties in receptive skills as weU. Expressive Language Disord er is not diagnosed if the criteria afe met for Autistic D isorder or another Pervasive Developmen tal Disorder. Autistic Disorder also involves expressive language impairment but may be d istingtlished from Expressi\-e and Mixed Receptive-Expressive Language Disorders by the characteri stics of the communication impairmen t (e.g., stereoty ped use of language) and by the presence
315.3 1
of a qualitative impainnent in social interaction and restricted, repetitive, and stereotyped patterns of behavior. Expressive and receptive language development may be impaired due to Mental Retardation, a hearing impairm ent or oth er sensory defi cit, a speechmotor deficit, or severe environm ental deprivation. The presence of these problems may be established by intelligence testing, audiometric tes ting, neurologi ca l testing, a nd history. U the language difficulties are in excess of those us ually associated with these problems, a concurrent diagnosis of Expressive Language or Mixed Recepli ve Expressive Language Disorder may be made. Children with expressive language delays due to environmental deprivation may show rap id gains once the environmen tal problems are ameliorated. In D isorder of Written Expression, there is a disturbance in writing skills. If deficits in oral expression are also presen t, an additional diagnosis of Expressive language Disorder may be appropria te. Selective Mutism involves limited expressive output that may mimic Expressive o r Mixed Receptive-Expressive Language Disorder; careful history and observation are necessary to determine the presence of normal language in some settings. Acq uired ap hasia associated w ith a general medical condition in childhood is often trans ient. A diagnosis of Expressive Language Disorder is a ppro priate only if the language disturbance persists beyond the acute recovery period for the etiological general medical condition (e.g., head trauma, viral infection).
Developmental Disorder. D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems. Coding note: If a speech-motor or sensory deficit or a neurological condit ion is present, code the condition on Axis III.
315.32
315 .32
Preva len ce
Prevalence estimates vary w ith age. It is estimated that the developmental ty pe of l\'lixed Recepti ve-Expressive Lang uage Disorder ma}' occur in up to 5% of preschool children and 3% of school-age dlildren but is probably less common than Expressive Language Disorder. Landau-Kleffner syndrome and o ther form s of the acqui red type of the disorder are relatively uncommon .
Course
The developmenta l type of Mixed Recep tive-Expressive Language Disorder is us ually detectable before age 4 years. Severe forms of the disorder may be apparent by age
Disorders Usually First Diagnosed in Infa ncy, Childho od, or Adolescence 2 years. Milder forms may not be recognized until the child reaches elementary school. where d efi cits in comprehension become more apparent. The acquired type of J\olixed Receptive-Expressive Language Disorder due to brain lesions, head trauma, or stroke may occur at any age. The acquired type due to Landau-Kleffne r syndrome (acquired epilep tic aphasia) usually occurs beh \'een ages 3 and 9 yea rs. Many child ren w ith Mixed Receptive-Expressive Language Disorder eventually acquire normal language abilities, but the prognosis is worse than for those with Expressive Language Disorder. In the acquired type of Nl.ixed Receptive-Expressive Language Disorder, the course and prognosis are related to the severity and loca tion of brain pathology, as well as to the age o f the child and the extent of language d evelopment at the time the disorder is acqu ired . Clinical improvement in language abilities is sometimes complete or nearly so. In other instances, there may be incomplete recovery or progressive deficit. Children with more severe forms are likely to develop Learning Disorders.
Familial Pattern
The developmental type of Mixed Receptive-Expressive Language Disorder is more common among first-degree biological relatives of those with the d isorder than in the general population. There is no evidence of fam ilia l aggregation in the acquired type of the disorder.
Differential Diagnosis
See the "Differential Diagnosis" section for Expressive Language Disorder (p. 60).
B. The difficulties with receptive and expressive language significantly interfere with academic or occupational ach ievement or with social commun ication.
C. Criteria are not met for a Pervasive Developmental Disorder.
D. If Mental Retardation, a speeCh-motor or sensory deficit, or environmental deprivat ion is present, the languag e difficult ies a re in excess of those usually associated with t hese problems. Coding note: If a speech-motor or se nsory deficit or a neurological cond ition is present, code the cond ition on Axis III .
PhonolOgical Disorder includes phonological production (Le., articulation) errors that involve the failu re to form speech sound s correctly and cognitively based forms of phonological problems that involve a deficit in linguistic categorization of speech sound s (e.g., a di ffi culty in sorting ou t which sounds in the language make a difference in meaning) . Severity ranges from little or no effect on speech intellig ibility to completely unintelligible speech. Sound omissions arc typically viewed as more severe than are sOWld substitutions, which in tum are more severe than sound distortions. The most frequently misarticulated sounds are those acqUired later in the developmental sequence (1, r, S, Z, til, ell), but in younger or more severely affected individ uals, consonants and vowels that develop earlier may also be affected. Li sping (i.e., misarticulation of sibilants) is particularly common . Phonological Disorder may also involve errors of selection and orderin g of sounds within syllables and words (e.g., aks for ask) .
66
Preva lence
Approxima tely 2% of 6~ and 7-year-old s present with moderate to severe Phonological Disorder, although the preva lence of milder forms of this disorder is higher. The prevalence falls to 0.5% by age 17 years.
Cou rse
In severe Phonological Disorder, the child's s peech may be relatively unintelligible
even to famil y members. Less severe fanns of the disorder rna)' n ot be recognized until the child enters a preschool or SdlOOl env ironment and has difficulty being unders tood by those outside the immediate family. The course of the disorder is variable depending on associated causes and severity. In children with mild to moderate phonological problems not due to a gene ral medical condition, abou t three-fo urths show spontaneous nomlalizatio n by age 6.
Familial Pattern
A fa milial pattern has been demonstrated for s ome form s of Phonological Disorder.
Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of It1 for target IkJ sound] or omissions of sounds such as final consonants).
B. The difficulties in speech sound production interfere w ith academic or occupational achievement or with social communication .
C. If Mental Retardation, a speech-motor or sensory deficit , or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.
Coding note : If a speech-motor or sensory deficit o r a neurological conditio n is present, code the condition on Axis III.
307.0
Stutte ring
307.0 Stuttering
Dia gnostic Features
The essential feature of Stuttering is a di sturbance in the nonnal fluency and time pa tterning of sp eech that is inappropria te for the individual 's age (C riterion A). This disturbance is characterized by freq uent repetitions or prolongations of sounds or syllables (Cri teria Aland A2). Various oth er types of s peech d ysfluencies may a lso be involved, including interjections (Criterion A3), bro ken words (e.g., pauses within a word ) (Criterion A4), audible or silent blocking (filled or unfilled pauses in speech) (Criterion AS), circumlocutions (i.e., word s ubstitutions to avoid p roblematic word s) (Criterion A6), words produced with an excess of physical tension (Criterion A7), and monosyllabic whole-word repetitions (e.g., " 1-1-1-1 see him") (Criterion AS). The disturbance in fluency interferes with academic or occupational achievement or with social communication (Criterion 8). If a speech-motor or sensor}' deficit is present, the speech difficulties arc in excess of those usu ally associated with these problems (Criterion C). U a sp eech-motor or sensory deficit or a n eurOlogica l disorder is present, trus condition s hould also be coded on Axis Ill. The extent o f the dis turbance varies from si tuation to situation and often is more severe w hen there is special p ressure to communicate (e.g., giving a report at school, interv iewi ng for a job). Stuttering is often absent during o ral reading, singing, or ta lking to inanimate objects or to pets.
Prevalence
The prevalence o f Stuttering in p repubertal ch ildren is 1% and drops to 0.8% in adolescence. The ma le-to-fema le ratio is approximately 3:1.
Course
Retrospective s tudies of individuals with Stuttering report onset typically between ages 2 and 7 years (with p eak onset at around age S years). Onset occurs before age 10 years in 98% of cases. The onset is us ually insidiou s, covering many months during
w hich episodic, unnoticed speech dysfluencies become a chronic problem. Typically, the dis tu rbance s tarts gradually, w ith repetition of initial consonants, words that are us ually the first w ords of a phrase, or long word s. The child is generally not aware of Stuttering. As the disorder progresses, there is a waxing and waning course. The dys flu encies become more frequent, and the Stuttering occurs on the mos t meaningful words or phrases in the utterance. As the child becomes aware of the sp eech diffi culty, mechanisms for avoiding the d ysfluencies and emotional resp onses may occur. Research s uggests that some p rop ortion recover; estimates range from 20% to 80%. Som e individuals with Stuttering recover s pontaneously, typically before age 16 years.
Familial Pattern
Family and tw in studies provide s trong evidence of a genetic fa ctor in the etiology of Stuttering. The presence of a Phonological Disorder or the developmental typ e of Expressive Language Disorder, or a fami ly history of these, increases the likelihood of Stuttering . The risk of Stuttering among first-degree biological relatives is more than three times the risk in the general population. For men with a h istory of Stutter ing, about 10% of their daughters and 20% of their sons will stutter.
Differential Diagnosis
Speech d ifficulties may be associated w ith a hearing impairment or other sensory def icit or a speechmotor deficit. In instances w here the speech difficulties are in excess of those usually associated with these problems, a concurrent diagnosis of Stu ttering may be made. Stuttering must be dis tinguished from normal dysfluencies that occur frequently in young children, w hich include w hole--word or phrase repetitions (e.g., "I want, I want ice cream "), incom plete phrases, interjections, unfilled pa uses, and paren thetica l remar ks. If these difficulties increase in frequency or complexity as the child grows older, a diagnosis of Stuttering becomes more likely.
307.9
69
8. The disturbance in fluency interfe res with academic or occupational achievement or with social communication.
Pervasive Developmental Disorders are characterized by severe and pervasive impairment in severaJ areas of development: reciprocal social interaction skills, communication skills, o r the presence of stereotyped behavior, interests, and activities. The qualitative impairments that define these conditions are distinctly deviant relative to the individual's developmental level or mental age. This section contains Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder, and Pef\'asive Developmental Disorder ot Otherwise Specified . These disorders are usuaU evident in the firs t years of life and are often associa ted with some degree of y Mental Retardation, which, if present, should be coded on Axis II. The Pef\'asive Developmental Disorders are sometimes obsef\'ed with a diverse group of other general medical conditions (e.g., chromosomal abnormalities, congenital infections, structur-
Disorders Usually First Diagnosed in Infancy, Childhood, o r Adolescence al abnormalities of the central nervous system). If such conditions are present, they should be noted on Axis Tn. Although terms like "psychosis" and "childhood schizophrenia" were once used to refer to individuals with these conditions, there isconsiderable evidence to suggest that the Pervasive Developmental Disorders are distinct from Schizophrenia (however, an individual with Pervasive Developmental Disorder may occasionally later develop Schizophrenia).
299.00
71
and the indi vid u al may he una ble to u nderstand simple questions or directions. A d istu rbance in the p rag matic (social use) of lan guage is often evidenced by an inability to integrate words w ith ges tures or unde rs tand hu mor or nonlite ral aspects of speech such as imny o r imp lied meaning. Imag inative p la y is often abse nt o r markedly impaired. These i.n divid u als also tend not to engage in the simple imita tion games or rou tines of infancy or early childhood or do so only out of context or in a mechanica l way. Lndividuals w ith A utis tic Disorder ha ve restricted , repetitive, a nd s tereotyped patterns of behavior, interests, and acti vities. There may be a n encompassing p reoccupation with one or more s te reotyp ed and restricted pa tte rns of inte res t that is abnormal either in intensity or focus (C rite rion A3a); a n a ppa ren tly inflexible adherence to s pecific, non fu nctional rou tines o r rituals (Cri terion A3b); s tereotyped and repe titive motor ma nnerism s (Criterion A3c); or a persis tent preoccupation with pa rts of objects (Criterion A3d ). Ind ividuals with A ut is tic Dis order d is play a markedly restricted range of in terests and are ofte n p reoccu pi ed w ith one narrow in te res t (e.g ., dates, phone nu mbers, radio sta tion call le tters). They may line up an exact numbe r of play things in the sa me manner ove r and over again or repetitively mimic the actions of a television actor. They may ins ist on sameness and sh ow resista nce to o r dis tress ove r tri vial changes (e.g ., a younge r child may have a catas lTophic reaction to a minor change in the environment such as rearrangeme n t of the fu m ihU"e or use of a new set of utens ils at the dinne r table). There is often an in teres t in nonfunctional routines or rituals or a n tmreasonable ins is tence on fo llowing routines (e.g ., taking exactl), the Scl me rou te to school e very day). Stereoty p ed body moveme nts include the hands (clapping, finger flicking) or whole body (rocking, dipping, and sw aying). Abnormalities of pos ture (e.g., walking on tip toe, odd hand movemen ts and body postures) may be p resen t. These individ uals s how a persis tent preoccupa tion with par ts of objects (buttons, parts o f the body). There m ay als o be a fa scination with movement (e.g ., the s pinning wheels of toys, the opening and closing of d oors, a n electric fan or other rapid ly revolving object). 1l1e p erson ma)' be highly a ttached to some inanima te object (e.g ., a piece of s tring or a rubber band). Th e d is turbance mus t be m anifes t by dela ys or abnormal functioning in a t leas t one (and often several) of th e following a reas p rior to age 3 yea rs: social inte raction, la nguage as used in social commu nication, or sym bolic or imaginative play (Criterion B). In mos t cases, the re is no period o f w lequ ivocaUy normal developmen t, although in perh aps 20% of cases parents report relatively normal developme nt for 1 or 2 years. In s uch cases, paren ts ma y report that the chi ld acquired a few word s and lost these or seemed to s tagnate developme ntally. By d efinition, if th e re is a period o f nom lal development, it cannot exten d pas t age 3 years. The distu rbance mus t not be better accoun ted for by Rett's Disorder or Childhood Disintegrative Disorder (Cri te rion C).
nHive skills is usually uneven, regardJess of the general level of intelligence, with verbal skills typically weaker than nonverbal skills. Sometimes special skills are present (e.g., a 41h-year-old girl with Autistic Disorder may be able to "decode" written materials w ith minimallmders tanding of the meaning of what is read [hyperlexia] or a I O-year-old boy may have prodigious abilities to calcula te da tes [calendar calculation]). Es timates of single-word (receptive or expressive) vocabulary are not always good estimates of language level (i.e., actual language skills may be at much lower levels) . Indi viduals with Autistic Disorder may have a range of behavioral symptoms, including hyperacti\'ity, short attention span, impulsivity, aggressiveness, self-injurious behaviors, and, particularly in young children, temper tantrums. There may be odd responses to sensory-s.timu li (e.g., a h igh threshold for pain, oversensitivity to smmds or being touched, exaggerated reactions to light or odors, fascination with certain s timuli). There may be abnormalities in eating (e.g., limiting diet to a few food s, Pica) or sleeping (e.g., recurrent awakening at night with rocking) . Abnormalities of mood or affect (e.g., g iggling or weeping for no apparent reason, an apparent absence of emotional reaction) may be present. There may be a lack of fear in response to real dangers. and excessive fearfu lness in response to harmless objects. A variety of selfinjurious behaviors may be presen t (e.g., head banging or finger, hand, or wrist biting). In adolescence or early adu lt life, individuals w ith Autistic Disorder who have the intellectual capacity for insight may become depressed in response to the realization of their serious impairment. Associated laboratory findings. When Autistic Disorder is associated with a general medical condition, laboratory fi ndings consistent with the general medical condition will be observed . There are group differences in some measures of serotonergic activity, but these are not diagnostic for Autistic Disorder. Imaging studies may be abnormal in some cases, but no specifi c pattern has been clea.rly identified. EEG abnormalities are common even in the absence of seizure disorders. Associated physical e xamination findings and general medical conditions. Various nonspecific neurological symptoms or signs may be noted (e.g., primitive reflexes, delayed development of hand dominance) in Autistic Disorder. The condition is sometimes observed in association with a neurological or other general medical condition (e.g., fragile X syndrome and tuberous sclerosis). Seizures may develop (particularly in adolescence) in as many as 25% of cases. Both microcepha ly and macrocephaly are observed . When other general medical conditions are presen t, they should be noted on Axis m.
Prevalence
The median rate of Autistic Disorder in epidemiological studies is 5 cases per 10,000 individuals, with reported rates ranging from 2 to 20 cases per 10,000 individuals. It remains unclear whether the higher reported rates reflect differences in methodology or an increased frequency of the condition.
Course
By definition, the onset of Autistic Disorder is prior to age 3 years . In some ins tances, parents will report that they have been worried about the child since birth or s hortl y afterward because of the child 's lack of interes t in social interaction . Manifestations of the disorder in infancy are more s ubtle and difficult to define than those seen after age 2 years. In a minority of cases, the child may be reported to ha ve developed normally for the fi rst }'ear (or even 2 }'ears) of life. Autistic Di sorder follo ws a continuou s course. In school-age children and adolescents, developmental gains in some areas are common (e.g., increased interest in social functioning as the child reaches school age). Some individuals deteriorate behaviorally during adolescence, whereas others improve. Language skills (e.g., presence of communicative speech) and overa ll intelleduillievel are the s trongest fac tors related to ultimate prognosis. Available follow up studies suggest that only a smaU percentage of individuals with the d isorder go on as adults to live and work independent1y. In about one-third of cases, some degree of partial independence is possible. The highest functioning adults with Autistic Disorder typically con tinue to exhibit problems in social in teraction and communication along with markedly restricted interes ts and activities.
Familia l Pattern
There is an increased risk of Autistic Disorder among Siblings of individuals with the disorder, with approximately 5% of siblings also exhibiting the condition . There also appears to be risk for various developmental d ifficulties in affected Siblings.
74
Disorders Usua lly First Diag nosed in Infa ncy, Childhoo d, o r Ado lescence
Differential Diagnosi s
Periods of developmental regression may be observed in normal development, but these are neither as severe or as prolonged as in Autistic Disorder. Autistic Disorder must be differentiated from other Pervasive Develo pmental Disorders. Rett's Disorder differs fro m Autis tic Disorder in its characteris tic sex ratio and pa ttern of deficits. Rett's Disorder has been d iagnosed only in females, whereas Autis tic Disorder occurs much more freque ntly in males. In Rett's Disorder, th ere is a characteristic pattern of head growth deceleration, loss of previously acquired purposeful h and skills, and the appearance o f poorly coordinated gai t o r trunk movements. Pa rticularly during the p resch ool years, ind ividuals \\'ith Rett's Disorder may exhibit difficul ties in social interaction si~r to those observed in Autistic Disorder, but these tend to be transient. Autis tic Disorder d iffers from C hildhood Disintegrative Disorder, w hich ha s a d is tinctive pa ttern of severe developmen tal regression in multiple areas of functi oning following at least 2 years of nomlal development. In Au tistic Disorder, developmental abnomla lities are usu ally noted wi th in the firs t year o f life. When information o n early development is unavailable o r when it is not possible to document the required period of normal development, the diagnosis of Autistic Disorder shou ld be made. Asperg ec's Disorder can be dis tinguished from Au tistic Di sorder by the lack of delay or deviance in early language develop ment. Asperger's Disorder is not diagnosed if criteria are met for Autistic Disorder. Schizophrenia with childhood onset us ually develops after years of nonnal, or near norma l, development. An additional diagnosis of Schizophrenia can be made if an individual with Au tistic Disorder develop s the characteristic feahu es of Schizophren ia (see p . 298) with active-phase symptoms of prominent delusions or hallucinations tha t las t for at least 1 month . In Selective Mutis m, the ch ild us ually exhibits appropria te commu nication skills in certain contexts and d oes not h ave the severe impa irment in social interaction and th e restricted patterns of behavior associated with Autistic Disorder. In Expressive Langu age Disorder and Mixed Recepli veExpressive Lang uage Disordcr, there is a lang uage impai m lent, bu t it is not associated with the presence o f a q ualitative impairment in social interaction and restricted, repetitive, and stereotyped patterns of behavior. It is sometimes d ifficult to determ inc whether an addi tional d iagnosis of All tistic Disord er is w arran ted in an individual with Mental Retardation, especially if the Mental Retardation is Severe or Profound. An additional diagnosiS of Autistic Disorder is reserved for those situations in w hich there are quali tative d eficits in social and commwlicative skills and the specific behaviors characteris tic of Autistic Disorder are present. Motor stereotypies are cha racteristic of Autistic Disorder; an addi tiona l d iagnosis of Stereotypic Movement Disorder is not given when these are better accounted for as part of the presentation of Autistic Disorder. Symptoms of overactivity and inattention are frequen t in Au tistic Disorder, but a d iagnosis of Attention-Deficit/Hyperacti vity D iso rd er is not made if Autistic Disorder is p resent.
75
,I,
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) (d) persistent preoccupation w ith parts o f objects B. Delays or abnormal fun ctioni ng in at least one of the following areas, with onset prior to age 3 years: (I) social inter action, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted fo r by Rett's Disorder or Childhood Disintegrative Disorder.
299.80
Diagnostic Features
Rett's Disorder
The essential fea ture of Relt's Disorder is the developmen t of multi ple specific deficits following a period of normal fun ctioning after birth_Ind ividuals have an apparently nonnal prenatal and perinatal period (Criterion A 1) w ith normal psychomotor developmen t through the first 5 months of We (Criterion A2). Head circum ferenceal birth is also within normal lim its (Criterion A3). Beh\'een ages 5 and 48 months, head growth decelerates (Criterion B1 ). There is a loss o f previously acquired purposeful hand skills behveen ages 5 and 30 months. with the subsequent development of char acteristic stereotyped Rand movemen ts resembling hand-wringing or hand washing (Criterion 82). Interest in the social environment diminishes in the fi rst fe w years after the onset of the disorder (Criterion B3), although social interaction may o ften d evelop later in the course. Problems develop in the coordination of gait o r trunk movements (Criterion 84). There is also severe impairment in expressive and recepti ve language development, w ith severe psychomotor retardation (Criterion 85).
Prevalence
Data are limited to mostly case series, and it appears that Rett's Disorder is much less common than Au tistic Disorder. This disord er has been reported only in females.
Course
The pattern of d evelopmental regression is highly d istinctive. Rett's Disorder has its onset p rior to age 4 years, usually in the firs t or second year o f life. The duration of the disorder is lifelong, and the loss of skills is generally persistent and progressive. In most instances, recovery is q uite limited, although some very m odest developmental gains rna)' be mad e and in terest in social interaction may be observed as individuals en ter later childhood or ado lescence. The communica tive and behavioral d ifficulties usually remain relatively constant throughout li fe.
Differential Diagnosis
Periods of develop mental reg ression may be observed in no rmal development, but these are neither as severe o r as prolonged as in Rett's Disorder. For the differential
299.10
diagnosis beh\'een Rett's Disorder and Autistic Disorder, see p. 74 . Rett's Di sorder d iffers from Childhood Disin tegrative Disord er and Asperger's Disorde r in its characteristic sex ratio, onset, and pattern of defidts. Rett's Disorder has been diagnosed only in females, whereas Childhood Disintegrative Disorder and Asperger's Disorder appea r to be more common in males. The onset o f symptoms in Rett's Disorder can begin as early as age 5 months, w hereas in Childhood Disintegrative Disorder the period of nonnal development is typically more prolonged (i .e., at least until age 2 years). In Rett's Disorder, there is a characteristic pattern of head growth d eceleration, loss of previously acquired purposeful hand skills, and the appearance of poorly coord inated gai t o r trwlk movements. In con trast to Asperger's Disorder, Rett's Disorder is dlaracterized by a severe impairment in expressive and receptive language development.
(2) appa rently norma l psychomotor development through the first 5 months after birth (3) normal head circumference at birth 8. Onset of all of the following after the period of norma l development:
(1) decele ratio n of head growth between ages 5 and 48 months
(2) loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent develo pment of stereotyped hand movements (e.g., hand-wringing or ha nd washing) (3) loss of social engagement early in the course (although often social interaction develops later) (4) appearance of poorly coordi nated gait or t runk movements (5) seve rely impaired expressive and rece ptive language deve lopment with severe psychomotor retardation
299.10
78
Ind iv iduals with this disorder exhibit the social and communicative de ficits and behaviora l features generaUy observed in Autisti c Disorder (see p. 70). There is q ualitative impainnent in social interaction (Criterion el ) and in co mmunication (Criterion e2), and restricted , repetitive, and stereotyped patterns of behavior, interests, and activities (Criterion C3). The d is tu rban ce is not better accoun ted for by another speci fi c Pervasive Developmen tal Disorder or by Schizophrenia (Criterion 0 ), This cond ition has also been te rmed Heller's syndrome, dell/cll tin ill/nlltilis, or disintegrative
Jlsyc/! osis.
Prevalence
Epidem iological data are limited, but Childhood Disin tegrative Disord er appears to be v ery rare and much less common than Autis tic Disorder, although the condition is likely underdiagnosed . Althoug h initjal s tud ies s ugges ted an equal sex ratio, the most recent d ata suggest that the cond ition is more comm on among males.
Co urse
By d efinition, C hildhood Disintegra tive Disord er can only be diagnosed if the symptom s are p receded by at leas t 2 years of normal d evelop ment and the onset is prior to age 10 years. Wh en the period o f normal development has been q ui te p rolonged (5 or more years), it is particularly imp ortant to cond uct a thorough p hysical and nellIelog ical examination to assess for the presence of a general medical con dition . In most cases, the onset is between ages 3 and 4 years and may be insidious or abrupt. Premonitory signs can include increased activity levels, irritability, and anxiety fo llowed by a loss of speech and other skills . Du ring this time, the d lild may also lose interest in the environment. Usually the loss of s kills reaches a p lateau, a fter which some limited improvemen t may occur, altho ugh imp rovement is rarely marked.. In other in s tances, esp ecially when the disorder is associated w ith a progressive neuro logical condition, the loss of skills is progressive. This disord er fo llows a continuous cou rse, and in the majority of cases, the duration is lifelong. The social, comm unicative, and behav ioral difficulties remain relatively cons tant throughou t life.
299 .10
79
Differentia l Diagnosis
Periods of regression may be observed in normal developmen l, but these are neither as severe o r as prolonged as in Childhood Disintegrative Disorder. Childhood Dis integra tive Disorder must be differentiated fro m other Pervasive Developmen tal Disorders. For the differential d iagnosis with Auti stic Disorder, see p. 74. For the differential diagnOSiS with Rett's Disorder, see p. 76. In contrast to Asperger's Disorder, Childhood Disintegrative Disorder is characterized by a cl inically significan t loss in previously acquired skills and a g rea ter likelihood of Mental Retardation. In Asperger's Disorder, there is no delay in language development and no marked loss of developmenial skills. Childhood Disintegrative Disorder must be differentiated from a demen tia with onset during infancy or childhood. Dementia occurs as a consequence of the direct physiological effects of a general med ica l condition (e.g., head tra uma), whereas Childhood Disinteg rative Diso rder typicaUy occurs in the absence of an associated general medical condition .
haviors, failure to develop pee r relat ionshi ps, lack o f social or emo tional reciprocity) (2) qual itative impairments in communication (e .g ., delay o r lack of spoken language, inability to in it iate o r sustain a conversation, st ereotyped and repet itive use of la nguage, lack o f varied make-bel ieve play) (3) restricted, repetit ive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and ma nnerisms O. The d isturbance is not bette r accounted fo r by a nother specific Pervasive Developmental Disorder or by Schizophrenia.
Iso
2 99.80
Diag nostic Feat ures
The essential (eahues of Asperger's Disorder are severe and sustained impairment in social interaction (Criterion A) and the development of restricted, repetitive patterns o f behavior, interests, and activities (Criterion B). The disturbance must cause c1inicaUy significant impa irment in social. occup ational, or other important areas of functioning (Criterion C). In contrast to Autistic Disorder, there are no clinica lly significant delays or d eviance in language acquisition (e.g., sin gle non-echoed words
are used communicatively by age 2 years, and spontaneous communicative phrases are used by age 3 years) (Criterion 0 ), although m OTe subtle aspects of social communication (e.g., ty pical give-and-take in conversation) may be affected. In addition, during the first 3 years of life, there are no clinical ly signHicantdelays in cognitive development as manifested by exp ressing normal curiosity abou t the environment or in the acquisition of age-app ropriate learning s kills and adaptive behaviors (other than in social interaction) (Criterion E). Finally, the criteria are no t met for another sp ecific Pervasive De\'eiopmentai Disorder or for Schizophrenia (Criterion F). This condition is also termed Asperger's syndrome. The impairment in reciprocal social interaction is gross and sustained. There may be marked impairment in the use of multiple nonverbal behaviors (e.g., eye-to-eye gaze, facial expression, body p ostures and gestures) to regulate social interaction and communication (Cri terion A 1). There may be failure to d evelop peer rela tionships app ropriate to developmental level (Criterion A2) that may take different forms at different ages. Younger individuals may have little or no interes t in establishing frien dships. Old er individuals may have an interest in fri endship bu t lack understanding of the conventions of social interaction . There may be a lack of s pon taneous seeking to s hare enjoyment, interests, or achievements with other people (e.g., not showing, bringing, or pointing out objects they find in teresting) (Cri terion A3). Lack of social or emotional reciprocity may be present (e.g., no t actively participating in simple social play or games, preferring solitary activities, o r involving others in activities only as tools or "mechanical" aids) (Criterion A4). Although the social deficit in Asperger's Disorder is severe and is defined in the same way as in Autis tic Disorder, the lack of social reciproci ty is more typically manifes t by an eccentric and one-sided social approach to others (e.g., pursuing a conversa tional topic regardless o f others' reactions) rather than social and emotional indifference. As in Autistic Disorder, restricted, repetitive patterns o f behavior, interests, and activities are present (Criterion B). Often these are primarily manifest in the development of encompassing preoccupations about a circumscribed topic or interest, about which the individual can amass a great d eal of facts a nd informa tion (Criterion Bl). These interests and acti vities are pursued with great intensity often to the exclusion of other activities. TIle d isturbance mus t cau se clinically significant impairment in social adaptation, w h ich in tum may have a significant impact on self-suffiency or on occupational or other important areas of functioning (Criterion C). The social deficits and restricted patterns o f interests, actjvities, and behavior are the source of considerable disability.
present have been noted (e.g., when the Mental Retardation becomes apparent only in the school years, with no apparent cogni tive or language d elay in th e first years of life). Variab ility of cognitive functioning may be observed, oft en w ith s treng ths in areas of verbal ability (e.g., vocabulary, rote auditory memory) and weaknesses in nonverbal areas (e.g ., visual-motor and Vis ual-sp atial skills). Mo tor c1 ll1I15iness and awkward ness m ay be present but u sually are relatively m ild , a lthough motor difficulties may contribu te to peer rejection and social isolation (e.g., inabili ty to participate in group sports) . Symptoms of overactivity and inattention are frequent in Asperger's Disorder, and indeed many individuals with this cond ition recei\'e a diagnosis o f Attention-Defi cit / Hyp eractivity Disorder prior to the d iagnosis of Asperger's Disorder. Asperger's Disorder has been reported to be associated with a number of other mental d isorders, includ ing Depressive Disorders.
82
Disorders Usua lly First Diagnosed in Infancy. Chi ldhood. or Ado lescence
o rder may experience \jctimiza tion by others; this, and feelings of social iso lation and an increasing ca pacity for self-awareness. may contribute to the development of depression and anxiety in adolescence and y OWlg ad ul thood . The disorder is diagnosed much more frequentl y (at leas t fi ve times) in males than in females
Prevalen ce
Definitive da ta regarding the prevalence of Asperger's Disorder are Jacking.
Course
Asperger's Disorder is a continuous and Welong disorder. In school-age children. good verbal abilities may, to some extent, mask the severity of the child's social d)'snmction and may also mislead ca regi vers and teachers-that is, caregivers and teachers may focu s on the dlild 's good verbal s kills but be ins ufficiently aware of p roblems in other areas (pa rticularly social adjus bnent). TIle child's rela tively good verbal skills may also lead teachers and caregi vers to erroneously a ttribute behavioral difficulties to willfulness or s tubbornness in th e child. Interes t in forming social relation sh ips may increase in adolescence as the ind ividuals lea rn some ways o f responding more adapti vely to their difficulties-fo r example, the individual may learn to apply explicit verbal rules o r routines in certain s tressful situations . Older individuals may have an interest in friend ship but lack unders tanding of the conventions o f social interaction and may more likely make relationships w ith individuals much older or younger than themselves. The prognosis appears significantly better than in Autistic Disorder, as follow up s tudies s ugges t that, as adults, many individuals are capable of gainful employmen t and personal selfsufficiency.
Familial Pattern
Although the available data are limited, there appears to be an increased frequency of Asperger's Disorder among famil y members of ind ividuals wh o have the disorder. There may also be an increased ris k for Autis tic Disorder as well as more general s0cial difficulties.
Differentia l Diagnosis
Asperger's Disorder mus t be dis tinguished from the other Pervasive Developmental Di sorders, all of which are characterized by problems in social interaction. It diffel'5 from Autistic Disorder in several ways. in Autistic Di sorder there are, by definition, significant abnom lali ties in the areas of social interaction, language, and play, whereas in Asperger's Disorder early cognitive and language s kills are not delayed sig nificantly. Furthermore, in Autistic Disorder, restricted , repetitive, and stereotyped interes ts and activities are often characterized by the presence of motor mannerisms, preoccupation with parts of objects, rituals, and marked distress in change, whereas in Asperger's Disorder these are primarily observed in the aUencompassing pursuit of a circumscribed interest involving a topic to which the individual devotes inordi nate am ounts of time amassing information and facts. Differentiation of the two (on-
299.80
Asperger's Disorder
83
ditions can be problematic in some cases . In Au tistic Disorder, typical social interaction patterns arc marked by self-isolation or markedl y rigid social approaches, whereas in Asperger's Disorder there may appear to be motivation for approaching others even though this is then done in a highly eccentric, one-sided, verbose, and insensitive manner. Asperger's Disorder mus t also be differentiated from Pervasive Developmental Disorders other than Autistic Disorder. Rett's Disorder differs from Asperger's Disorder in its characteristic sex ratio and pattern of deficits. Rett's Disorder has been d iagnosed only in females, whereas Asperger's Disorder occurs much more frequently in males. In Rett's Disorder, there is a dlaracteristic pattern of head growth deceleration, loss of previously acquired purposeful hand skills, and the appearance of poorly coordinated gait or trunk movemen ts. Rett's Disorder is also associated with marked degrees of Mental Retardation and gross impairments in language and communication. Asperger's Disorder differs from Childhood Disintegrative Disorder, which has a distinctive pattern of developmental regression follo wing at least 2 years of normal development. Children with Childhood Disintegrative Disorder also display marked degrees of Mental Retardation and language impairment. In contrast, in Asperger's Disorder there is no pattern of d evelopmental regression and, by defini tion, no significan t cognitive or language delays. Schizophrenia o f childhood onset usually develops after years of nonnal, or near normal, development, and characteris tic features of the disorder, including hallucinations, delusions, and disorganized speech, are present. In Selective Mutism, the child usually exhibits appropriate comnumication skills in certain contexts and does not have the severe impairnlent in socia l interaction and the restricted patterns of behavior associated with Asperger's Disorder. Conversely, individuals w ith Asperger's Disorder are typically "erbose. In Expressive Language Disorder and Mixed Receptive-Expressive Language Disorder, there is language impairment but no associated qualitative impairment in social interaction and restricted, repetitive, and stereotyped patterns of behavior. Some individuals w ith Asperger's Disorder ma y exhibi t behavioral patterns suggesting Obsessive-Compulsive Disorder, although s pecial clinical attention should b e given to the differentiation between preoccupations and activities in Asperger's Disorder and obsessions and comp ulsions in ObsessiveCompulsive Disorder. In Asperger's Disorder these interests are the source of some apparent pleasure or comfort, whereas in Obsessive-Compuls ive Disorder they are the source of anxiety. Furthennore, Obsessive-Compulsive Disorder is typically no t associated with the level of impairment in social interaction and social communication seen in Asperger's Disorder. The relationship between Asperger's Disorder and Schizoid Personality Disorder is unclear. In general, the social difficulties in Asperger's Disorder are more severe and of earlier onset. Although some indiv id uals with Asperger's Disorder may experience heightened and debilitating anxiety in social settings as in Social Phobia or other Anxiety Disorders, the latter conditions are not characterized by pervasive impairments in social development or by the circumscribed interests typical of Asperger's Disorder. Asperger's Disorder must be distinguished from normal social awkwardness and nonnal age-appropriate interes ts and hobbies. In Asperger's Disorder, the social deficits are quite severe and the preoccupa tions are all-encompassing and interfere with the acqu isition of basic skills.
Qualitative impairment in social interaction, as manifested by at least two of the fol lowing:
(1) marked impairment in the use of mult iple nonverbal behaviors such as eye-to-
eye gaze, facial expression, body postures, and gestu res to regu late social inter action (2) failure to develop peer relationsh ips appropriate to developmental level (3) a lack of spontaneous seeking to sha re enjoyment, int erests, or achievemenu with other people (e.g., by a lack of showing, b ring ing, or pointing out objeru of interest t o other people) (4) lack of social or emotional reci proci t y B. Restricted repetit ive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (1) encompassing preoccupation w ith one or more stereotyped and restricted pal terns of interest that is abnormal either in intensity or focus (2) apparentl y inflexible adherence to specific, nonfunctional routines or rituals (3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flappi ng or twisting, or complex whole-body m ovements) (4) persistent p reoccupat ion with parts of objects
299.80 Pervasive Developmental Disorder Not Otherwise Specified (Including Atypical Autism)
This category should be used wh en there is a severe and pervasive impairment in thi! development of reciprocal social interaction associa ted with impairment in either verbal or nonverbal communication skills or with the presence of s tereotyped beha\" ior, interests, and activities, but the criteria are not met for a specific Pervasive De\'e~ opmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this category includes "atypica l autism "-presentations that do not meet the criteria for Autistic Disorder because of late age ,1t onset, atypical symptomatology, or subthreshold symptomatology, or all of these.
8s 1
Attention-Deficit/Hyperactivity Disorder
Diagnostic Fe atures
The essential featwe of Attention-Deficit / Hyperactivity Disorder is a persis tent pattern of inattention and / o r hyperactivity-impulsivity tha t is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development (Criterion A). Some h yperactive-i mpulsive or inattentive symptoms that cause impairment mu st have been present before age 7 years, although many individuals are diagnosed after the sym p toms have been present for a number of years, esp ecially in the case of individuals with the Predominantl}' lnattentive Type (Criterion B). Some impairment from the symptoms mus t be present in at least two settings (e.g., at home and at school or work) (Criterion C). There mus t be clear evidence of interference with developmentally appropria te social, academic, or occupational functioning (Criterion D). The d isturbance does no t occwexclusively dwing the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and is not better accounted for by another mental disorder (e.g., a t-.'Iood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder) (Criterion E). Inatten tion may be manifest in academic, occupational, or social situations. Individuals with this disorder may fail to give dose attention to detai ls or may make careless mistakes in schoolwork or other tasks (Criterion Ala). Work is often messy and performed ca relessly and without considered though t. Indiv id uals often have difficulty sustaining attention in tasks or play activities and often find it hard to persist with tasks until completion (Criterion Alb). They often appear as if their mind is elsewhere or as if they are not listening or did not h ear what has jus t been said (Criterion Ale). There may be frequent sh ifts from one uncompleted activity to another. individuals diagnosed with this disorder may begin a task, move on to another, then tum to } something else, prior to completing anyone las k:",T hey often d o not follow 'et through on requests or ins tructions and fail to complete schoolwork, chores, o r other duties (Criterion AId). Failure to complete tasks should be considered in making this diagnosis only if it is due to inattention as opposed 10 other possible reasons (e.g., failure to unders tand instructions, d efiance). These indivi duals often ha ve difficulties organizing tasks and activ ities (Criterion Al e). Tasks that require sustained mental effort are experienced as unpleasant and markedly aversive. As a result, these individuals typically avoid or have a strong dislike for activities that demand sustained self-application and mental effort or that require organizational demands or dose concentration (e.g., homework o r paperwork) (C riterion 1:-1 f). This avoidance mus t be due to the p erson's difficulties w ith attention and not d ue to a primary oppositional attitude, although secondary oppositionalism may also occur. Work habits are often disorganized and the materials necessary for doing the task are often scattered, lost, or carelessly handled and damaged (Criterion Alg). Individuals with this disor-
86
dec are easily distracted by irrelevant stim uli and frequentl y interrupt ongoing tasks to attend to trivial noises or events that a re usually and easily ignored by others (e.g., a car honking, a background conversation) (Criterion A Ih). They are often forgetfu l in daily activities (e.g., missing appoinhnents, forgetting to bring hmch) (Criterion A 1i). In social situations, inattention may be exp ressed as freque n t shifts in con versation, not listening to others, n ot keeping one's m ind on conversations, and not following details or rules of gam es or ac ti\,jties. Hyperactivity may be manifested by fid getiness o r squirming in one's sea t (Cri lerion A2a), by not remaining scated when expected to do so (Criterion A2b), by excessive numing or climbing in s ituations w he re it is inappropriate (Criterion A2c), by having difficulty playing or engaging quietly in leis ure activities (Criterion A2d), by appear~ ing to be often "on the go" or as if "driven by a m otor" (Criterion A2e), or by talking excessively (Criterion A2f). H yperactivity m ay vary w ith the individual's age a nd developmental level, a nd the d iagnosis s hould be m ade cautiously in yOlmg children. Toddlers and preschoolers w ith this disorder di ffer from normally active young children by being constantly on the go a nd into everything; they da rt back and fo rth, are "out of the door befo re their coat is on," jump or climb o n furniture, run through the house, a nd ha ve difficulty participating in sedentary group activities in presdlool classes (e.g ., listening to a s tory). School-age children display similar behaviors but usually w ith less frequency or intensity than toddlers and preschoolers . TIley have difficulty remai ning seated, get up frequentl y, a nd squirm in, or hang on to the edge of, the ir sea t. They fid get with objects, tap their hand s, a nd s hake their feet or legs excessive ly . They o fte n get up fro m the table during m eals, w hile watching television, or w hile doing homework; they talk excessively; and they make excessive noise during q uiet activities . in a dolescen ts and a dults, sym ptom s of h yp eractiv ity take the form of feelings of restlessness and difficulty engaging in quiet seden tary activities. lmpulsivity manifests itself as impatience, difficulty in de laying responses, blurting o ut answers before qu estions have been completed (Criterion A2g), difficulty awaiting one's tum (Criterion A2h), and frequently inte rru p ting or intrud ing on othe rs to the point of causing difficulties in socia l, academic, or occupational settings (Criterion A2i). Others m ay com pla in tha t they cannot get a w o rd in e dgewise. Individ uals w ith this disorder typically make com men ts out of tum, fail to listen to directions, initiate conversations at inapp ro priate times, interrupt others excessively, intrude on o thers, grab objects from others, touch things they are not supposed to touch, and clow n around . Impu lsivity may lead to accidents (e.g., knocking over objects, bangi ng in to people, g rabbing a hot pan) and to engagemen t in potentia lly dan gero us activities without consideration of possible consequences (e.g., re peatedly climbing to p recarious pos itions or riding a skateboard over extrem e ly rough terrain). Attentional and behavioral manifes tations us ually appear in multiple contexts, incl uding home, school, work, and social situations . To make the diagnosis, some impairment mlls t be present in at least hvo settings (Criterion C). It is very unusu al for a n individual to display the same level of d ysfunction in all settings or wi thin the saille setting at a ll times. Sym p to m s typ ically worsen in situa tions that require sustai.ned attention or m ental e ffort or that lack intrinsic appeal o r novelty (e.g ., listening to classroom teachers, do ing class assigrunents, lis tening to or reading lengthy matE'rials, or working on monotonous, repetitive tasks). Signs of the disorder may be m inim al o r absent w hen the person is receiving frequent rewards for app ropriate
87
behavior, is lU\der close supervis ion, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situa tion (e.g., the clinician's office). The symptoms are more likely to occur in g roup situations (e.g., in pJaygroups, classrooms, or work e nvironments). The clinician should therefore gather information from multiple sources (e.g., parents, teachers) and inqu ire about the individual's be havior in a variety of situa tions within each setting (e.g., d oi ng homework, having meals).
Subtypes
Although many indi viduals present with symptoms of both inaltention and hype ractivity -impu ls ivity, there are indi viduals in w hom one or the other pattern is predominant. The appropria te subtype (for a current diagnosis) should be indicated based on the predominant symptom pattem fo r the past 6 months.
314.01 Attention-DefidtIHyperactivity D isord er, Comb in ed Type. This s ubtype shouJd be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity -impulsivity have persis ted for at least 6 months. t\'lost ch ildren and adolescents with the disorder have the Combined Type. It is not known whether the same is true o f adults with the disorder. 314.00 Attention-De ficit/Hyperactivity Disorder, Predominantly lna tte ntive Typ e. This subtype s hould be u sed if six (or more) symptoms of inattention (but few er than six symptoms of h yperactivity-impulsivity) have persisted for alleast 6 months. Hyperactivity may still be a significant clinical feature in many such cases, whereas other cases are more purely inattentive. 314.01 Atten t ion-Deficit/Hyperactivi ty Disorder, Predominan tly H yperactive-Impulsive Type. This subtype should be u sed if six (or more) symptoms of hype ractiv ity-impuJs ivity (but fewer than six symptoms of inattention) have p ersisted for a t least 6 months. Inattention may often s ti.ll be a Significant clinical feature in such cases.
Associated d escripti ve f e ature s and mental disorde rs. Associated fcahlfes vary depending on age and d evelopme ntal s tage a nd may include low fru stration tolerance, temper outbursts, bossiness, stubbofIUless, excessive and frequent insis te nce
88
Disord ers Usually First Diagnosed in Inf ancy, Chi ldhood. or Ado lescence
that requests be met, mood lability , demora li za tion, d ysphoria, rejection by peers, and poor sel f-es teem. Acad emic achievement is oft en marked ly impaired and devalued, typically leading to conflict with the fa mily and with school au thorities. lnadequate self-application to tasks that require sustained effort is often interpreted by others as indicating laziness. a poor sense of res pons ibility. and oppositional behavior. Family rela tionships are often characterized by resentment and antagonism, especially because variability in the individual's symptomatic s tatus oft en leads others to believe that all the troublesome behavio r is w ill ful. Family d iscord and negative pa rent-child inter,lctions are often present. Such nega tive interactions often diminish w ith s uccessful treatment. On average, in dh 'iduals w ith Atten tion-Deficit/ Hyp eractivity Disorder obtain less schooling than their peers and h ave p oorer vocational achievemen t. Also, on average, inteUectual level, as assessed by individual lQ tests, is several p oints lower in ch ildren with this d isorder compared with peers. At the same time. great variability in IQ is evidenced : in dividuals with Attention-Deficit/ Hyp eractivity Disorder may show intellectual development in th e above-average or gi fted range. In its severe form, the disorder is markedly impairing. affecting social, fa m ilial, and scholastic adjus tment. All three s ubtypes are associated with significant im pairment. Academic defi cits and school-related problems tend to be most pranounced in the types marked by ina ttention (Predominantly Ina ttentive and Combined Types), whereas peer rejection and, to a lesser extenl, accidental injury are most salient in the types marked by hyperactivity and imp ulsivity (Predominan tly Hyperactive-lmp u lsive and Combined Typ es). Individua ls w ith the Predominantly Inattentive Type tend to be socially passive and appear to be neglected, rather th an rejected, by peers. A substantial proportion (approximately half) of clinic-referred child ren with Attention-Deficit/ Hyperactiv ity Disord er also have OppOSitional Defia nt Disorder or Conduct Disorder. The rates of co-occurrence of Attention-Defi ci t/ Hyperactivity Disorder w ith these other Dis ruptive Behav ior Disorders are hig her than with other mental d isord ers, and this co-occurrence is most likely in the h vo s ubtypes marked by hypera c ti \ri ty~impu lsi v ity (Hyp eractive-lmpu lsl\re and Combined Types). Other associated d isorders include Mood Disord ers, Anxiety Disorders, Leam ing Disord ers, and Communication Disorders in child ren with Atten tion-Defi ci t/ Hyperacti\ity Disord er. Although A tte nti o n~ Defici t / H )'p e ra c ti "i ty Disorder appears in at leasl 50% o f dinic-referred individuals w ith Tou rette's Disord er, most ind ivid uals with Attention-Deficit/ Hyperactivity Disorder do not have accompanying Tourette's Disorder. When the h\'o disord ers coexis t, the onset o f the Atten tion-Deficit/ Hyperacti\,ity Disorder often p recedes the onset of th e Tourette's Disord er. There may be a his tory of ch ild abuse or neglect, multiple foster placements, neu rotoxin exp os ure (e.g., lead poisonin g), infec tions (e.g ., encephalitis), d rug exposure in u tero, or Mental Retardation. Although low bi rth weight ma y so metimes be associated with Atten tion-Defi cit/H yperactivity Disord er, mos t children with low birth weight do not develop Atten tion-Deficit/ Hyp eractivity Disord er, and most children with Attention-Defici t / Hyperactivity Disord er do not have a h is tory of low birth weight. Associated laboratory findings . There are no labora to ry tes ts, neurolOgical assessmen ts, or attentional assessments that have been establis hed as d iagnos tic in the d in-
Attention-Deficit/Hyperactivity Disorder
89
iea l assessmen t of Attention-Deficit/ Hyperactiv ity Disorder. Tests that require effortful m ental processing have been noted to be abnormal in groups of ind ivi duals with Attention-Deficit / Hyp eractivity Disorder compared with p eers, b ut these tests are not of demonstrated utility when one is trying to determine whether a particular individual has the disorder. It is not yet known what ftmdamental cognitive deficits are responsible for sum group differences.
Associated physical examination findings and general medical conditions. There are no s pecific physical features associated with Attention-Deficit/ Hyperactivity Disorder, although minor physical anomalies (e.g., hypertelorism, highly arched palate, low-set ea rs) may occur at a higher r-ate than in the general population . There may also be a higher rate of acciden tal physical injury.
90
Ch ildhood, or Adolescence
The disorder is more frequent in males than in females, with male-In- female ratios ranging from 2:1 to 9:1 , depending on the type (i.e., the Predominantly Inattentive Type may have a gender ratio that is less pronounced) and setting (Le., clinic-referred dilldren are morc likely to be male).
Preva lence
The prevalence of Attention-Defi cit/ Hyperactivity Disorder has been es timated at 3%-7% in school-age children . These reported rales vary d epending on the nature of the pop ulation sampled and the method of ascertainment. Data on prevalence in .1d oleseence and adulthood are limited . Ev idence s uggests that the prevalence of Attention-Deficit / H yp eractivity Disorder as defined in DS~'l-IV may be somewhat greater than the prevalence of the disorder based on DSM-III -R criteria because of the inclusion of the Pred ominantly Hyperacti ve-Impulsive and Pred ominantly Ina ttentive Types (which would have been diagnosed as Attention-Defi cit Hyperacti vity Disord er Not Otherwise Sp ecified in DSM-III-R).
Co urse
Most parents firs t observe excessive motor activity when the children are todd lers, frequently coinciding with the d evelopment o f independent locomotion. However, becau se many overactive toddlers w ill not go on to develop Attention- Deficit/ Hyperactivity Disorder, special attention should be paid to differentiating nonnal overactivity from the hyperactivity characteris tic of Attention-Defi cit/ H}'peracti vity Disorder before making this diagnosis in early years. Usually, the disorder is fi rst diagnosed during elementary school years, when school adjustment is compromised. Some children with the Predominantly Inattentive Typ e may not come to clinical attention lmtillate childhood . In the majority of cases seen in clinical settings, the disorder is relatively s table through early adolescence . In most indiv iduals, symptoms (particularly motor hyperactivity ) attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of Atten tion-Deficit/ H yperactiv ity Disorder into mid-adulthood. O ther adults may retain only some of the symptoms, in w hich case the diagnosis of Attention-Deficit/ Hyperacti vity Disord er, In Partial Rem.ission, should be used. The latter diagnosis applies to individuals w ho no longer have the full disorder but s till retain some symptoms th at c aliSI.' functional impairment.
Familial Pattern
Attention-Deficit/ Hyp eractivity Di sord er has been fOWld to be more common in the first-degree biological relatives of chi ldren with A ttention-Defici t! Hyperactivity Disorder tha n in the general population . Considerable evidence attests to the s trong infl u ence of genetic factors on levels of hyp eractivity, impulsivity, and inattention as measured dimensionally . However, famil y, sch ool, and peer influences are also crucial in d etermining the extent of impairments and comorbidity. Studies also suggest that there is a higher prevalence of Mood and Anxiety Disorders, Learning Disorders, Subs tance-Related Disorders, and Antisocial Personality Disord er in famil y members of individuals with Attention-Deficit/ Hyp eracti vity Disorder.
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Differential Diagnosis
In early childhood, it may be difficult to distinguish symptoms of Attention-Deficit/ Hyperactivity Disorder from age-appropriate behaviors in active children (e.g., running arOlmd or being noisy). Symptoms of inattention are common among children with low IQ who are placed in academic settings that are inappropriate to their intellectual ability. These behaviors must be distinguished from similar signs in clilldren with Attention-Deficit/ Hyperactivity Disorder. In children with Mental Retardation, an additional diagnosis of Attention-Deficit/ Hyp eractivity Disorder should be made only if the symptoms of inattention or hyperactivity are excessive for the child's mental age. Inattention in the classroom may also occur when children with high inteUigenceare placed in academically understimulating environments. Attention-Deficit/ Hyperactivity Disorder must also be distinguished from difficulty in goal-dire<:ted behavior in children from inadequate, disorganized, or chaotic environments. Thorough histories of symptom pattern obtained from multiple infomlants (e.g., baby-sitters, grandparents, or parents of playmates) are helpful in providing a confluence of observations concerning the child's inattention, hyperactivity, and capacity for developmentally appropriate self-regulation in various settings. Individuals with oppositional behavior may resis t work or school tasks that require self-application because of an unwillingness to conform to others' demands. These symptoms must be differentiated from the avoidance of school tasks seen in individuals with Attention-Defi cit/ Hyperactivity Disorder. Complicating the differential diagnosis is the fact that some individuals with Attention -Deficit/ Hyperactivity Disorder develop secondary oppositional attitudes toward such tasks and devalue their importance, often as a rationalization for their failure. The increased motor activity that may occur in Attention-Deficit/ H yperactivity Disorder must be distinguished from the repetitive motor behavior that characterizes Stereotypic Movement Disorder. In Stereotypic Movement Disorder, the motor behavior is generally focused and fixed (e.g ., body rocking, self-biting), whereas the fidgetiness and restlessness in Attention-Deficit/ Hyperactivity Disorder are more typically generalized. Furthermore, individuals with Stereotypic Movement Disorder are not generally overactive; aside from the stereotypy, they may be underactive. Attention-Deficit / Hyperactivity Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder (e.g., Mood Disorder [especially Bipolar DisorderJ, Anxiety Disorder, Dissociative Disorder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Substance-Related Disorder). In all these disorders, the symptoms of inattention ty pically have an onset after age 7 years, and the childhood history of school adjustment generally is not characterized by disrupti\'e behavior or teacher complaints conceming inattentive, hyperactive, or impulsive behavior. When a Mood Disorder or Anxiety Disorder co-occurs with Attention-Deficit/ Hypefilctivity Disorder, each should be diagnosed . Attention-Deficit/ Hyperactivity Disorder is not diagnosed if the symptoms of inattention and hyperactivity occur exclusively during the course of a Pervasive Developmental Disorder or a Psychotic Disorder. Symptoms of inattention, hyperactivity, or impulsivity related to the use of medication (e.g., broncllOdilators, isoniazid, akathisia from neuroleptics) in children before age 7 years are not diagnosed as Attention-Deficit/ Hyperactivity Disorder but instead are diagnosed as Other Substance-Related Disorder Not Othenvise Specified.
Either (1) or (2): (1) six (or more) of the fo llowing sympto ms of inattention have persisted for at least 6 months to a degree t hat is maladaptive and inconsistent w ith developmenta l level: .
Inattention
(a) often fail s to g ive close attention to details or makes careless mistakes in schoolwo rk, work, or other activities (bl often has difficulty sustaining attention in tasks or play activities (cl often does not seem to listen when spo ke n to di rectly (d) often does not follow throu gh on instructions and fails to fin ish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (el often has d iff iculty organizing tasks and activities (f) often avoids, disl ikes, o r is reluctant to engage in tasks that require sus tained mental effort (such as schoolwork o r homework) (g) often loses t hings necessary fo r t asks o r activities (e.g ., toys, school aSSign. ments, pencils, books, o r tools) (h) is often easily d istracted by extraneous stimuli (i) is often fo rgetful in daily activities (2) six (or mo re) of the following symptoms of hyperactiv ity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets w ith ha nds o r feet or squi rms in seat (b) often leaves seat in classroom o r in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective fee lings of restlessness) (d) often has difficulty playing or engag ing in leisure activities qu iet ly (el is often "on the goN o r often acts as if Ndriven by a motor" (f) often talks excessively
Impulsivity
(g) often blurts out answers before q uestions have been completed (h) often has d ifficulty awa iting turn (i) often interru pts or intrudes on o thers (e.g., butts into conversations or ga mes) B. Some hyperactive-impulsive or inattentive symptoms that cau sed impairment were prese nt before age 7 years.
C. Some impairment fro m the symptoms is present in two or more settings (e.g., at school lor work] and at home).
314.01 AttentionDefidtlHyperactivity Disorder, Combined Type: if both Crit eria Al and A2 are met for the past 6 months 314.00 Attention .DefidtlHyperactivity Disorder, Predominantly Inattentive Type : if Crit e rion A1 is met but Crite rion A2 is not met fo r the past 6 months 314.01 Attention.DefidtlHyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria. "In Partial Remission " should be specified.
314.9
This category is for disorders with prominent symptoms of inattention or hyperactivity impulsivity that d o n ot meet criteria fo r Atiention. Oefi cit/H yp eractivity Disorder. Examples include
1. lndividuaJs whose symptoms and impairment meet the crite ria for Attention Deficit/ H yperactivity Disorder, Predominantly Inattentive Type bu t whose age at onset is 7 years or aft e r ~ 2. Individuals wi th clinically s ignificant impairment who present w ith inatten tion and w hose symptom pattern d oes not meet the full c rite ria for the disorder but have a be hav ioral pattern marked by sluggishness, daydreaming, and hypoac tjvity
Conduct Disorder
Diag nostic Features
The essentia l feature of Conduc t D isorde r is a repetitive and pers is te nt pattern of behavior in which the bas ic rights of others or major agC"'appropria te societaJ norms or rules a re violated (Criterion A). These behaviors fall into fo ur main g roupings:
Disorders Usually First Diagnosed in Infancy, Childhood, o r Adolescence aggressive conduct that causes or threatens physical harm to other people or animals (Criteria AI-A?), nonaggressive conduct that causes property loss or damage (Criteria AS--A9), deceitfulness or theft (Criteria AIO--AI2), and serious violations of rules (Criteria Al 3--AI 5). Three (or more) characteristic behaviors mus t ha\'e been p resent during the past 12 months, with at least one behavior present in the past 6 months. The disturban ce in behavior cau ses clinically significant impairment in social, acad emic, or occupational functioning (Criterion 8). Conduct Disorder may be diagnosed in individuals who are older than age 18 years, but only if the criteria for Antisocial Personality Disorder are not met (Criterion C). The behavior pattern is u su ally present in a variety of settings such as home, school. or the community. Because individual s w ith Conduct Disorder are likely to minimize their conduct problems, the clinician often must rely on additional infonnants. However, the infor mant's knowledge of the child's conduct p roblems may be limited by inadequate superv ision or by the child's not having revealed them . Children or adolescents with this disorder often initiate aggressive behavior and react aggressively to others. They may display bullying, threatening, or intimidating beha vior (Criterion AI); initiate frequent physical fights (Criterion A2); use a weapon that can cause serious physical harm (e.g., a bat, brick, broken bottle, knife, or gun) (Criterion A3); b e physically cruel to people (C riterion A4) or animals (Criterion AS); s teal while confronting a victim (e.g., mugging, purse snatching, extortion, or armed robbery) (Criterion A6); or force someone into sexual activity (Criterion A7) . Physical violence may take the fonn of rape, assault, or, in rare cases, homicide. Deliberate des truction of others' property may include deliberate fire setting with the intention of causing seriou s damage (Criterion A8) or deliberately des troy ing other people's prop erty in other ways (e .g., sm ashing car windows, school vandalism) (Criterion A9). Acts of deceitfulness or theft may include breaking into someone else' s house, bu ilding, or car (Criterion AIO); frequentl y lying or b reaking promises to obtain goods or favors or to avoid debts or obligations (e.g., "conning" other people) (Criterion All ); or .s tealing items of nontrivial value without confronting the victim (e.g., shoplifting, forgery) (Criterion AI2). There may also be serious violations of rules (e.g ., school, paren tal) by individuals with this disorder. Children w ith this d isorder often have a pa ttern, beginning before age 13 years, o f s taying out late at night despite parental prohibitions (Criterion A13). There may be a pa ttern of running aw ay from home overnight (Criterion AI 4). To be consid ered a symptom of Conduct Disorder, the numing away mus t have occurred at least twice (or only once if the individual did not return for a lengthy p eriod). Run away episodes that occur as a direct consequence of physical or sexual abuse do not typicany qualify for this criterion. Children with this disorder may often be truant from school, beginning prior to age 13 years (Criterion AI 5) . In older individuals, this behavior is manifested by often being absent from work w ithout good reason.
Subtypes
Two subtypes of Conduct Disorder are provided based on the age at onset of the dis ord er (i.e., Childhood -Onset Type and Adolescent-Onset Type). The subtypes differ in regard to the characteris tic nature of the presenting conduct problem s, develop-
Conduct Disorder mental course and prognosis, and gendee ratio. Both subtypes can occur in a mild, moderate, or severe fonn.1n assessing the age at onset, information should preferably be obtained fro m the youth and from caregiver(s). Because many of the behaviors may be concealed, caregivers may underreport symptoms and overestimate the age at onset. 312.81 Chil dhood-Onset Type. This subtype is defined by the onset of a t least one criterion characteristic o f Conduct Disorder prior to age 10 years. Indiv idua ls with Childhood-Onset Type are usua lly male, frequently display physical aggression toward others, have disturbed peer relationships, may have had Oppositional Defiant Disorder during early childhood, and usually have symptoms that meet full criteria for Conduct Disorder prior to puberty. Many children with this subtype also have concurrent Attention-Deficit l Hyperactivity Disorder. Individuals with Childhood-Onset Type are more likely to have persistent Conduct Disorder and to develop adult Antisocial Personality Disorder than are those w ith Adolescent-Onset Type. 312.82 Adolescent-Onset Type. This subtype is defined by the absence of any criteria characteristic of Conduct Disorder prior to age 10 years. Compared with those w ith the Childhood-Onset Type, these individual s are less likel)' to display aggreSSive behaviors and tend to have m ore nonnative peer relationships (although they often d isplay conduct problems in the company of others). These individuals are less likely to have persistent Conduct Disorder or to develop ad ult Antisocial Personality Disorder. The ratio of males to fe males with Conduct Disorder is lower foe the Adolescent-Onset Type than for the Childhood -Onset Type. 312.89 Unspecified Onset. This subtype is used if the age at onset of Conduct Disorder is unknown.
Severity Specifiers
M ild . Few if any conduct problems in excess of those required to make the d iagnosis are present, and conduct p roblems cause relatively minor hann to others (e.g., lying, truancy, staying Ollt aftee dark without pennission). Mode rate. The number of conduct problems and the effect on others are in, termediate between "mild" and "severe" (e.g., stealing w ithout confronting a victim, vandalism ). Severe. Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing w hile confronting a v ictim, breaking and entering).
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justified . They may be callous ilnd lack appropriate feelings of guilt OT remOTSe. It can be difficult to evaluate whether displayed remorse is genuine because some of these ind ividuals learn that expressing guilt may reduce or prevent punishmenl. Ind ividuals with this disorder may readily inform on their companions and try to b lame oth
ers for their own misdeeds. Self-esteem may be low, despite a projected image of
" toughness." For other individuals, measured sel f-esteem may be overly inflated. Poor frustration tolerance, irritability, temper outhu rsts, and recklessness are frequent associated features. Accid ent rates appear to be higher in individuals with Conduct Disorder than in those w ithout it. Conduct Disorder is o ften associated with an early onset of sexual behavior, d rinking, smoking, use of illegal substances, and reckless and risktaking acts_ lllegal drug use may increase the ris k that Conduct Disorder will persist. Conduct Disorder behaviors may lead to school s uspension or expulsion, problems in work adju s tm en~ legal difficulties, sexually transmilled diseases, unplanned pregnancy, and physical injury from acciden ts or fights. These problems may preclud e attendance in ordinary schools or living in a parental or foster h ome. Suicidal ideation, suicide attempts, and completed suicide occur at a hi gher than~expected ra le. Conduct Disorder may beassociated with lower~ than~average intelligence, particularly with regard to verballQ. Academic achievement, particularly in reading and other verbal skills, is often beiOlI' the level expected on the basis o f age and intelligence and may jus tify the additional diagnosis of a Learning o r Communication Disorder. Attention~Deficit / Hypera cth" ity Disorder is common in children with Conduct Disorder. Conduct Disorder may also be associated with one or more of the following mental disorders: Learning Disorders, Anxiety Disorders, Mood Disorders, and Substance-Related Disorders. The following factors may predispose the individual 10 the development of Conduct Disorder: parental rejection and neglect, difficult infant temperament, inconsis tent child rearing practices w ith harsh diSCipline, physical or sexua l abuse, lack of supervision. early institutional living, frequent changes of caregivers, large fami ly size, history of maternal smoking during pregnancy, peer rejection, association with a delinquent peer group, neighborhood exposure to violence, and certain kinds of familial psychopathology (e.g., Antisocial Personali ty Disorder, Substance Dependence or Abuse).
Associated laboratory findings. In some studies, lower heart rate and lower skin conductance have been noted in individuals with Conduct Disorder compared with those without the disorder. However, levels of physiological arousal are not diagnostic of the disorder.
context would not necessarily warrant a diagnosis of Conduct Disorder. It may be helpful for the clinician to consider the social and economic context in which the undesirable behaviors have occurred. Symptoms of the disorder vary with age as the individual develops increased physical strength, cognitive abilities, and sexual maturity. Less severe behaviors (e.g., lying, shoplifting, physical fi ghting) tend to emerge first, w hereas olhers (e.g ., burglary) tend to emerge later. Typically, the most severe conduct problems (e.g., rape, theft w hile confronting a victim) tend to emerge last. However, there are wide differences among individuals, with some engaging in the more damaging behaviors at an early age (which is predictive of a worse prognosis). Conduct Disorder, especially the Childhood-Onset Type, is more common in males. Gender differences are also found in s pecific types of conduct problems. Males with a diagnOSiS of Conduct Disorder frequently exhibit fig hting, s tealing, vandalism, and school discipline problems. Females with a diagnosis o f Conduct Disorder are more likely to exhibit lying, truancy, running away, subs tance use, and prostitution. Wherea s confrontational aggression is more often displayed by males, females tend to use more nonconfronrntional behaviors.
Preva lence
The prevalence of Conduct Disorder appears to have increased over the last decades and may be higher in urban than in rural settings. Rates vary widely depending on the nature of the population sa mpled and methods of ascertainment. General population s tudies report rates ranging from less than 1 % to more than 10%. Prevalence rates are higher among males than females. Conduct Disorder is one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children.
Course
The onset of Conduct Disorder may occur as early as the preschool years, but the first Significant symptoms us ually emerge during the period from middle childhood through middle adolescence. Oppositional Defiant Disorder is a common precursor to the Childhood-Onset Typ e of Cond uct Disorder. Onset is rare after age 16 years. The course of Conduct Disorder is variable. In a majority of indi"idua ls, the disorder remits by adulthood. Howe"er, a s ubstantial proportion continue to show behaviors in adulthood that meet criteria for Antisocial Personality Disorder. Many individuals with Conduct Disorder, particularly those with Adolescent-Onset Type and those with few and milder symptoms, achieve adequate social and occupational adjustment as adults. Early onset predicts a worse prognosis and an increased risk in adult life for Antisocial Personality Disorder and Substance-Related Disorders. Individuals with Conduct Disorder are at risk for later Mood Disorders, Anxiety Disorders, Somatoform Disorders, and Substance-Related Disorders.
F amilia l Patte rn
Estimates from twin and adoption studies show that Conduct Disorder is influenced by both genetic and environmental facto rs. The risk for Conduct Disorder is increased
98
in children with a b iological or adoptive parent with Antisocial Personality Disorder or a sibling with Cond uct Disorder. The disorder also appea rs to be mo re common in dlilrlren of biological parents with Alcohol Dependence. Mood Disorders, o r Schizophrenia or biological parents who have a history of Attention-Deficit/ Hyperactivity Disorder or Conduct Disorder.
Differential Diagnosis
Although Opposit ional Defiant Di so rder includes some of the features observed in Cond uct Disord er (e.g., disobedience and opposition to authority figu res), it does not include the persis tent pattern of the more serious forms of behavior in which either the basic rights of others or age-appropriate societal norms or rules are violated. When the individual's pattern of behavior meets the criteria for both Conduct Disord er and Oppositional Defiant Disorder, the diagnosis of Conduct Disorder takes precedence and O p positional Defiant Disorder is no t diagnosed. Although child ren with Attenti on-Deficit/Hyperactivity Disorder often exhibit hyperactive and impulsive beha vior that may be d isn lptive, this behavior does not by itself violate age-appropriate societal norms and therefore does not usually meet criteria for Conduct Disorder. When criteria are met for both Attention-Defid t/ Hyperactivity Disorder and Conduct Disorder, both d iagnoses should be given . Irritability and conduct problems often occur in children or adolescen ts with a Mood Disorder. These can us ually be dis tinguished from the pattem of conduct problems seen in Conduct Disorder based on the episodic course and accompanying symptoms characteris tic of the Mood Disorder. If criteria for both are met, diagnoses of both Conduct Di sorder and the Mood Disorder can be given. The diagnosis of Adjustment Di sorder (With Dis turbance of Conduct or With Mixed Dis turbance o f Emotions and Conduct) should be considered if clinically significant conduct problems tha t do not m eet the criteria for another specific disorder d evelop in clear association with the onset of a p sychosocial s tressor. Isola ted conduct problems that do not meet criteria for Conduct Disorder or Adjustment Disorder may be coded as Child or Adolescen t Antisocial Behavior (see "Additiona l Conditions That May Be a Focus of Clinical Attention," p. 740). Conduct Disorder is diagnosed only if the conduct p roblems represent a repetitive and persis tent pattem that is associa ted with impai rment in social, academic, or occupational fun ctioning.
major age-appropriate societal norms or rul es are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals (1 ) often bullies, threatens. or intimidates others (2) often initiates physical fights (3) has used a wea pon that can cause serious physica l harm to others (e.g., a bat, brick, broken bottle, knife, gun)
Conduct Disorder
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312.81 Conduct Disorde r, Childhood-Onse t Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years 31 2.82 Conduct Disorder, Adole sce nt -Onse t Typ e: absence of any criteria characteristic of Conduct Disorder prior to age 10 years 312 .89 Conduct Disord e r, Unspecifi ed Onse t : age at onset is not known
Specify severity:
Mild : few if any conduct problems in excess of those required to make the diagnosis a nd conduct problems cause only minor harm to others Mode ra t e: number of conduct problems and effect on others intermediate between "mild " and "severe" Severe: many conduct problems in excess of those requ ired to make the diagnosis or conduct problems cause considerable harm to others
For irldividuals over age 18 years, a diagnOSis of Conduct Disorder can be given only if the criteria are not also met for Antisocial Personality D iso rder. The diagnosis of Antisocial Personality Disorder cannot be given to individuals under age 18 years.
313.81
Diagnostic Features
The essential feature of Oppositiona l Defiant Disorder is a recurrent pa ttern of negativis tic. defiant, disobedient. and hostile behavior toward authority fi gures that persists for at leas t 6 months (Cri terion A) and is characterized by the frequent occurrence of at least four of the follow ing behaviors: losing temper (Criterion Al), arguing with adults (Criterion A2). actively defying o r refusing to com ply with the reques ts or rules of adults (C riterion A3), deliberately doing things that w ill annoy other people (Criterion A4), blaming o thers for his or her own mistakes or misbehavior (Criterion AS), being touchy or easily annoyed by o thers (Criterion A6), being angry and resentful (Criterion A7), o r being spiteful or vind ictive (Criterion AS). To qualify fo r Oppositional Defiant Disorder, the behaviors must occur mo re frequentl y than is ty pically observed in individu als of comparable age and developmental level and must lead to significant impairment in social, academic, o r occupational functioning (Criterion B). The diagnosis is not made if the dis turba nce in behavior occurs exclusively during the course of a Psychotic or Mood Disorder (Criterion C) or if criteria are met for Conduct Disorder or Antisocial Personality Disorder (in an individual over age 18 years). Negativistic and defiant behaviors are expressed by persistent stubbornness, resistance to directions, and unwillingness to co mpromise, give in, or n egotiate with adults or peers. Defiance may also include deliberate or persis tent testing of limits. usually by ignoring orders, arguing. and faili ng to accept blame for misdeeds. Hostility can be directed at adults or peers and is shown by deliberately annoying others or by verbal aggression (usually without the more serious physical aggression seen in Conduct Disorder). Manifestations of the disorder are almost invariably present in the home setting, b ut may not be evident at school or in the community. Symptoms of the disorder are typically more evident in interactions with adults or peers whom the individual knows well, and thus m ay not be apparent during clinical examination. Usua lly individuals with this disorder do not regard themselves as oppositional or defiant, but ju stify their behavior as a response to unreasonable d emands or circumstances.
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inconsistent, o r neglectful child-rearing practices are common. Attention-Deficit / Hyperactivity Disorder is common in children with Oppos itional Defiant Disorder. Learning Disorders and Communication Disorders also tend to be associated with Oppositional Defiant Disorder.
Prevalence
Rates of Oppositional Defiant Disorder from 2% to 16% have been reported, depend ing on the nature of the population sample and methods of ascertainment.
Course
Oppositional Defiant Disord e r usually becomes evident before age 8 years and usu ally not later than earl )' adolescence. The oppositional symptoms ofte n emerge in the home setting but over time may appear in other settings as well. O nset is typ ically gradual, u sually occurring over the course of months or yea rs. In a s ignificant propor tion of cases, Oppositional Defiant Disorder is a developmental antecedent to Can duct Disorde r. Although Conduct Disorder, ChildhoodOnset Type is o ften preceded by O ppositional Defiant Disorder, many children with Oppositiona l Defiant Dis order do not subsequently d evelop Conduct Disorder.
Familial Pattern
Opposi tional Defiant Disorde r a ppea rs to be more common in fam ilies in which at least one pare nt has a h istory of a Mood Disorde r, Oppositional Defiant Disorder, Conduct Disorder, A ttentionDeficit/ H yp eractivity Disorde r, Antisocia l Personality Disorder, or a Subs tance-Related Disorder. in addition, some studies s uggest that mothers with a De pressive Disorder are more likely to have dilldren with oppositional behavior, but it is lUlciear to what extent maternal depression res ults from orcau ses oppositional be havior in children. Oppos itional Defiant Disorder is marc common in families in which there is seriou s marital d iscord.
Differential Diagnosis
The dis ruptive behaviors of individuals with O p positional Defiant Disorder are of a less seve re nature than those of individuals w ith Conduct Disorder and typically do not include aggression tow,ud people or animals, d estruc tion of prope rty, or a pa t-
102
Disorders Usua lly First Diagnosed in Infa ncy, Chi ldhood, or Ado lescence
tern o f theft or deceit. Because all of the features of Oppositional Defiant Disorder are usu ally present in Condu ct Disorder, Oppositional Defian t Disorder is not diagnosed if the criteria are met for Conduct Disorder. Oppositional behavior is a common associated fea ture of Mood Disorde rs and Psycho ti c Disorders presenting in children and ado lescen ts and should no t be diagnosed separately if thes)rmptoms occur exclusively during the course of a Mood or Psychotic Disorder. Oppositional behaviors mus t also be dis tinguished fro m the d isruptive behav ior resulting from inattention and impulsivity in Attention-Deficit/Hyperactivity Disorder. When the two disorders co-occur, both d iagnoses should be made. In indiv id uals with Men tal Retardation, a diagnosis of Oppositional Defiant Disorder is g iven only if the oppositional behavior is markedly greater than is commonly observed among individuals of comparable age, gender, and severity of Mental Retardation. Oppositional Defiant Disord er must a lso be d istinguished from a failure to foll ow directions that is the result of im paired language com prehension (e.g., hearing loss, Mixed ReceptiveExpressive Language Disorder). Oppositional behavior is a typica l fea tu re of certain d evelopmental stages (e.g., early childhood and adolescence). A diagnosis of Oppositional Defiant Disorder should be considered only if the behaviors occur more frequently and have more serious consequences than is typically observed in other ind ividuals of comparabledeveiopmental stage and lead to significant impairment in social, academic, or occupational fun ctioning. New onset o f oppositional behaviors in adolescence may be due to the p rocess of normal individuation.
often loses temper often argues with adults often actively defies or re f uses to comply with adults' requests or rules often deliberately annoys people often blames others f or his or her mistakes or misbehavior is often touchy or easily annoyed by others is often ang ry and resentful is often spitef ul or vindictive
Note : Consider a criterion met only if the beh avior occurs more frequently than is typically observed in individuals of comparable ag e and developmentalleveJ. B. The disturbance in behavior causes cl inically significan t impairment in social, academic. or occupational functioning.
C The behaviors do not occur exclusively during the course of a Psychotic or M ood Disorder.
D. Crit eria are not met for Conduct Disorder, and, if the individual is age 18 years or older, crit eria are not met for Antisocia l Personality Disorder.
312.9
312.9
This category is for dis orders characterized by conduct or oppositional defiant behaviors that do not meet the crite ria for Conduct Disorder or Oppos itional Defiant Disorder. For example, include clinical presentations that do not meet full criteria either for Oppositional Defiant Disorder or Conduct Disorder, bu t in w hich there is clinically Significan t impairment.
307 .52
Diagnostic Features
Pica
The essential feature of Pica is the eating of one or more n onnutritive substances on a persistent basis for a period. of a t least 1 month (Criterion A). The typical substances ingested tend to vary w ith age. Infants and younger children typically eat paint, pIaster, string, hair, or cloth. O lder children may eat a nimal droppings, sand, insects, leaves, or pebbles. Ad olescents and adults may consume clay or soil. There is no aversion to food . This behavior mus t be developmentally inappropriate (Criterion B) and not part of a culturally sanctioned practice (Criterion C). The eating of nonnutritive substances is an associated feature of other men tal disorders (e.g., Pervasive Developmental Disorder, Mental Reta rdation). If the ea ting behavior occurs exclusively during the course of another m ental disord er, a separate diagnOSiS of Pica should be made only if the eating behavior is s ufficiently severe to warrant independe nt clinical attention (Criterion D).
or infections su ch as toxoplasmosis and toxocariasis as a result of ingesting feces or dirt). Poverty, neglect, lack of parenta l supervision, and developmental delay increase the ri sk for the condition.
Preva lence
Epidemiological data on Pica are limited. Among individ uals with Men tal Retardation, the prevalence of the di sorder appears to increase wi th the severi ty of the retardation (e.g., it has been reported to be as high as 15% in adults with Severe Mental Retardation).
Course
Pica may have its onset in infancy. In most instances, the disorder appears to last for several months and then remits. It may occasionally continue into adolescence or, less freq uently, into adulthood. In individua ls with Mental Retardation, the behavior may diminish during adulthood .
Differential Diagnosis
Before approximately ages 18-24 months, mouthing and sometimes eating of noonutritive substances are relatively common and d o not imply the presence of Pica. Pica is d iagnosed only when the behavior is judged to be persistent (i.e., present for at least 1 month) and inappropriate given the indiv idual's developmental level. Eating of nonnutriti ve substances may occur during the course of other mental disorders (e.g., in a Pervasive Developmental Disorder, in Schizophrenia as a result of delusional beliefs, and in Kleine-levin syndrome). In such instances, an additional diagnosis of Pica should be given only if the eating behavior is sufficiently severe to warran t independent clinical attention. Pica can be d istinguished from oth er eating disorders (e.g., Rumination Disord er, Feeding Disorder of Infancy or Early Childhood, Anorexia Nervosa, and Bulimia Nervosa) by the consumption of noonutritive substances.
307.53
D. If the eating behavior occurs exclusively during the course of another mental disorder (e .g., Menta l Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention.
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Diag nostic Feat ures
Rumination Di sorder
The essential feature of Rumination Disorder is the repeated regurgitation and rechewing of food occurring after feeding that develops in an infant or child after a period of normal functioning and lasts for at least 1 month (Criterion A). Partially digested food is brought up into the mouth without apparent nausea, retching, disgust, or associated gas trointestinal disorder. The food is then either ejected from the mouth or, more frequently, chewed and reswallowed . The symptoms are not due to an associated gastrointestinal or o ther general medical condition (e.g., Sandifer's syndrome, esophageal renux) (Criterion B) and do not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa . If the symptoms occur exclusively during the course o f Mental Retardation or a Pervasive Developmental Disorder, they mus t be suffiCiently severe to warrant independ ent clinical attention (Criterion C). The disorder is most commonly observed in infants but may be seen in older individuals, particularly those who also have Mental Retardation. Infants with the disorder dis play a characteristic position of stra ining and arching the back with the head held back, make sucki ng movements with their tongues, and give the imp ression of gaining satisfaction from the activity.
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regurgitated material. In some instances, Feeding Disorder of Infancy or Early Childhood may a lso develop. In older chi ldren and adults, Mental Retardation is a predisposing factor.
Preva lence
Rumination Disorder appears to be uncommon . It may occur more often in males than in females.
Course
The onset of Rumination Disorder may occur in the con text of developmen tal delays. The age at onset is between ages 3 and 12 months, excep t in individuals with Mental Retardation in \\'hom the disorder may occur at a somewhat later developmental stage. In infants, the disorder frequently remits s pontaneously. In some severe cases, however, the course is continuous.
Different ia l Diagnosis
[n infants, co nge nital anom alies (e.g ., pyloric s tenos is or gastroesophageal reflux) or other general m edica l conditions (e.g., infections of the gastrointes tinal system) can cause regurgitation o f food and s hould be ru led out by appropriate physical examinations and laboratory tests. Rumination can be dis tinguished from norm al vomiting of early infancy by the a pparent ly voluntary nature of the rumination (e.g., observation of characteristic preparatory movements followed by regurgitation and sucking o r chewing movements that appear to be pleasurable). Rumination Disorder is nol diagnosed if the symptoms occur exclusively durin g the course of Anorexia Nervosa or Bulimia Nervosa.
limia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficiently severe to warrant independent clinical attention.
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107
307. 59
Pre va lence
Of all pediatric hospital admissions, 1%-5% are for failure to thrive, and tip to oneha lf of these may reflect feeding dis turbances without any appare nt predisposing
108
Disorders Usually First Diagnosed in Infancy, Chi ldhood, or Adolescence
general medical condition . Data from community samples suggest a point prevalence of around 3% fo r failure to thrive.
Cou rse
Feeding Disorder of Infancy or Early Childhood commonly has its onset in the fi rst
yea r o f life, but may h ave an onset in children ages 2-3 years. The majority of children have improved growth after variable lengths of time, although they remain shorter and lighter up through adolescence compared with children who did not experience growth failure.
Differential Diagnosis
Minor problems in feeding are common in infancy. The diagnosis of Feeding Disorder of In fancy or Early Childhood should be made only if the eating problem resu lts in signifi cant failure to gain weight or loss of weight. This d isorder is not diagnosed if the feeding distur bances are fully explained by a
gastro intes tinal, endocri nological, or neurological cond ition. Children with an underlying general medica l condition may be more difficult to feed , and the diagnosis of Feeding Disorder of Infancy or Early Childhood sh ould not be mad e in such cases unless the degree of d istu rbance is of g reater severity than would be expected o n the basis of the general m edical condition alone. The diagnosis is suggested if there is impro\'ement in feeding and weight gain in response to changing caregivers.
nificant failure to gain weight or Significa nt loss of weight over at least 1 month. B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g . esophagea l reflux).
C. The disturbance is not better accounted for by anot he r menta l disorder (e.g., Rumi-
nation Disorder) or by lack of avai lable fo od. D. The onset is before age 6 years.
Tic Disorders
Fourdisorders are included in this section: Tourette's Disorder, Chronic Motor or Vocal Tic Disorder, Transient Tic Disorder, and Tic Disorder Not Otherwise Spedfied. A tic is a sudden, rapid , recurren t, nonrhythmic, s tereotyped motor movement or vocalization. Motor and vocal tics may be simple (involv ing only a few muscles or
Tic Disorders
109 1
simple soWlds) or complex (involving multiple groups of muscles recruited. in orchestrated bouts or words and sentences). Examples of silllple lIIotor tics are eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, and abdominal tensing. These tics usually last less than severa l hundred milliseconds. Complex motor tics include hand gestures, jumping, touching, pressing, stomping, facial contortions, repeatedly smelling an object, squatting, deep knee bends, retracing steps, tw irling when wa lking, and assuming and holding unus ual postures (including "dystonic tics" such as holding the neck in a particular tensed pos ition). These tics are longer in duration, lasting seconds or longer. Copropraxia (a s udden, tic-like vulgar, sexual, or obscene gesture) and mirror phenomena such as echopraxia (invoIWltary, s pontaneous imitation of someone else's m ovements) are complex motor tics. Simple vocal tics are meaningless sound s su ch as truoat clearing, grunting, sniffing, snorting, and chirping. Complex vocallics more clearly involve speech and language and include the sudden, spontaneous expression of single words or phrases; speech blocking; sudden and meaningless changes in the pitch, emphas is, or volume of speech; palila lia (repeating one's own sound s or words); and echolalia (repeating the last-heard sound, word, or phrase). Coprola lia is the sudden, inappropriate expressionol a socially unacceptable word or phrase and may include obscenities as well as specific ethnic, racial, or religious slurs. Coprolalia is found in fewe r than 10% of individuals with a tic disorder. Tics genera lly are experienced as irresis tible but can be suppressed for varying lengths of time. Some children (and an occasional adult) are not aware of their tics. However, with d evelopment, many (but not a ll) p ersons w ith tics experience a premoni tory urge-a rising tension or s omatic sensation in a part of the body that precedes the motor or voca l tic, and a fee ling of relief or tension red uction following the expression of the tic. lndividuals with tics may feel that the tic is between "vo luntary" and "involuntary" in that it is often experienced as a giving in to a mounting tension 01 bodily need, similar to the tension that precedes a sneeze or the almost irresis tible need to scratch an itch. An individual may feel the need to perform a complex tic in a specific way or repeatedly until he or she achieves the feeling that the tic has been done "just right. " Only then will the individual experience a reduction in the anxiety or tension. Tics are often emi tted in bouts of one or several tics; the bouts are separated by periods of non-tic behavior lasting from second s to hours. Tics generally change in se\'erity (freq uency of tics, forcefulness, and the degree tics disrupt ongoing behavior) during the course of hours and over the course of a day. Tics may va ry in frequency and d isruptiveness in different contexts. For example, children and adults may be better able to s uppress tics when in school, at work, or in the physician 's office than at home. Tics generally decrease o r s top during sleep, although some individuals have occasional tics w hile asleep or awaken suddenly with a tic. Tics are often more freque nt w hen a person relaxes in private (e.g ., when watching television) and are decreased w hen the individual engages in directed, eHortful activ ity (e.g., reading or sewing). Tics may be exacerba ted during period s of s tress, s uch as w hen there are heightened work pressures or during examinations.
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Tourette's Disorder
111
sym p toms o f both Obsessive-Compulsive Disorder and a Tic Disorder (especially Tourette's Disorder), both diagnoses may be warranted . Certain vocal or motor tics (e.g., ba rking, echolalia, palilaHa) m ust be d istinguished from d isorganized or catatonic behavior in Schizophrenia. The Tic Disorders can be distin guished from one another based on d uration and variety of tics and age a t onset. Transient Tic Disorder includes motor and / or vocal tics lasting fo r at least 4 weeks but for no longer than 12 consecutive months. Touretle's Disorder and Chronic Motor or Vocal Tic Disorder each have a duration of m ore than 12 months, but Touretle' s Disorder requires multiple motor tics and at least one vocal tic during pa rt of this time. Often, the diagnosis may change over time during the na tural history of a Tic Disorder. For example, during the first months, a child may be d iagnosed as having a Transient Tic Disorder. After a year, w ith fu rther tics and lon ger duration, the diagnosis may become Tourelte's Disorder. Ti c Disorder Not Othenvise Specified would be appropriate for clinically significa nt p resentations lasting less than 4 weeks, for presentations w ith an age at onset above age 18 years, and for the unusual case of an individ ual with only one mo tor tic and only one vocal tic.
1 112
frequ ently occur. Persistent motor and voca l tics may cause a broad range of distress
and impairment, ranging from none to severe. Younger children, in particula r, may be unaware o f their tics, suffer no distress, and show no impa irment in any area of functioning. A high percentage of child ren, adolescen ts, and adults with Tourette's Disorder do not seek medical allention for their tics . At the other end of the spectrum, there are individuals w ith Tourette's Disorder who are b urdened by in trusive, recurrent, forcefu l, and SOCially stigma tizing motor and voc31 tics. Socia l, academic, and occupational functioning may be impaired because of rejection by o thers or anxiety about having tics in social situations. Chronic tic symptoms can cause considerable d istress and can lead to social isolation and personality changes. In severe cases of Tourette's Disord er, the tics may d irectly interfere with daily activities (e.g., conversing, reading. or writing). Rare complications o f Tourette's Disorder include physical injury, such as blindness due to self-inflicted eye injury (from head banging or eye gouging), orthopedic problems (from knee bending, neck jerking, or head turn ing), skin p roblems (from picking or lip licking), and neurological sequelae (e.g., from disc d isease rela ted to many years of fo rceful neck movements). The severity of the tics may be exacerbated by administration of centra l nervous system stirn ulants, such as those used in the treatment of Attention-Deficit/Hyperactivity Disord er, although some individua ls can tolerate these medications withou t an exacerbation of their tics or may even have a reduction in tics. ObseSSive-Compulsive Disorder and Atten tion-Deficit/ Hyperactivity Disorder often co-occur in individuals with Tourette's Disorder. Attentional problems or obsessive symptomatology may p recede or foll ow the onset of tics. ObseSSive-compulsive symptoms found in individuals with Tourette's Disorder may constitute a specific subtyp e of ObsessiveCompulsive Disorder. TIlis subtype appears to be characterized by an earlier age at onset, male p reponderance, higher frequency of certain obsessive-compulsive s}'mptoms (more aggressive s}'mptoms and less concern about contamina tion and hoarding), and poorer resp onse to p harmacotherap}' with selective serotonin reuptake inhibitors. Disruptive behavior, impulsiveness, and social im maturity are prominent features in those children and adolescents who also have Atten tion-Defi ci t/ Hyperactivity Disorder. These clinical features may interfere with academic progress and interpersonal relationships and lead to greater impairment than that cau sed by the Tourette's Disorder.
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Prevale n ce
The prevalence of Tourette's Disorder is related to age. Many more children (S-30 per 10,000) are affected than adul ts (1-2 per 10,(00).
Cou rse
The age at onset of Tourette's Disorder may be as early as age 2 years, is usually during childhood or early adolescence, and is by definition before age 18 years. The median age at onset for motor tics is about 6-7 years. The duration of the disorder may be lifelong, though periods of remission lasting from weeks to years may occur. In most cases, the severi ty, frequen cy, disruptiveness, and variability of the symptoms diminish during ad olescence and adulthood. In other cases, the symptoms actually disappear entirely, lIsually by early adulthood. In a few cases, the symptoms may worsen in adulthood. The predictors of this course are no t known.
Fa milial Pattern
The vulnerability to Tourette's Disorder and related disorders is transmitted within fam ilies and appears to be genetic. The mode of genetic transmission, however, is not known. Pedigree studies suggest that there are genes of major effect. Although some early studies suggested a pattern of transmission that is consistent with an autosomal domina nt pattern, other studies suggest a more complex mode of transmission. "VuJnerability" implies that the child receives the genetic or constitutional basis for developing a Tic Disorder; the prease type or severity of disorder may be different from one generation to another and is modified by nongenetic factors. Not everyone w ho inherits the genetic \' ulnerability will express symp toms of a Tic Disorder. The range of forms in which the vulnerability may be expressed includes Tourette's Disorder, Chronic Motor or Voca l Tic Disorder, and some forms of Obsessive-Compulsive Disorder. It also appears that individuals with Tourette's Disorder are at greater risk for Attention-Deficit/ Hyperactivity Disorder. In some individuals with Tourette's Disord er, there is no evidence of a familial pattern.
Differential Diagnosis
Refer to the "Differential DiagnosiS" section for Tic Disorders (p. 110).
1 114
B. The tics occur many times a day (usually in bouts) nearly every da y or intermittently throughout a period of more than 1 year, and during th is period there wa s never a tic-free period of mo re than 3 consecutive mo nths.
C. The onset is before age 18 years.
D. The disturbance is not due to the direct physiological effects of a substance (e.g . st imulants) or a general medical condition (e.g., Huntington's disease or portviral encephalit is).
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Diagnostic Features
The essential fea ture of Chronic Mo tor or Vocal Tic Disorder is the presence of either moto r tics or vocal tics, but lIot both (Criterion A). This differs from T ourette's Disorder in which there must be both multiple motor and one or more vocal tics. The other essential features (Criteria B, C, and D) are the same as for Tourette's Disorder. A diagnosis of Chronic Motor or Voca l Tic Disorder cannot be made if the criteria for Tourette's Disorder have ever been met (Criterion E). The other characteristics of Chronic Motor or Vocal Tic Disorder are generally the same as for Tourette's Disorder (see p. 111), except that the severity of the symptoms and the fun ctional impairment are usually much less. It appears that Chronic Motor or Vocal Tic Disorder and Tourette's Disorder may be genetically related because the}' often occur in the same families.
Differential Diagnosis
Refer to the " Differential Diagnosis" section for Tic Disorders (p. 110).
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115
riod of more than 1 year, a nd during th is period there was never a t ic-free period of mo re than 3 co nsecutive mo nths.
C. The onset is before age 18 years.
D. Th e disturbance is not due to the direct physiological eHects of a substance (e.g., stimulants) or a genera l medical condition (e.g., Huntingto n's disease or postviral en cephalitis).
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Diag nostic Features
Tr ansient Ti c Di sorder
The essential feature of Transient Tic Disorder is the presence o f single or multiple motor tics and / or vocal tics (Criterion A). The tics occur many tim es a day, nea rly every d ay for at least 4 weeks, but for no longer than 12 consecutive months (Criterion 6). The other essential features (Criteria C and D) are the sam e as for Tourette's Disorder. Transient Tic Disorder is n ot d iagnosed if the criteria fo r Tou rette's Disorder or Chronic Motor or Vocal Tic Disorder (both of w hich require a duration of at least 1 year) have ever been met (Criterion E). The other characteristics of the disorder are generally the same as for Tourette's Disorder (see p. 111), except that the severity of the symp toms and the functi onal impa irment are usually much less.
Specifiers
The course of Transient Tic Disorder may be indicated by specifying Single Episode or Recurren t.
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B. The tics occu r many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
C. The onset is before age 18 years.
D. The disturbance is not due t o the direct physiological effects of a substance (e.g . stimulants) or a general medical condition (e.g., Huntington's disease or portvira l
encephal itis) . E. Cr iteria have never been met fo r laurette's Disorder or Chronic Motor or Vocal Tic Disorder.
Specify if:
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This category is for disorders characterized by tics that do nol meet criteria for a specific Tic Disorder. Examples include tics lasting less than 4 weeks or tics with an onset
after age 18 years.
Elimination Di sorders
Encopresis
Diagnosti c Features
The essential feature of Encopresis is repeated passage of feces into inappropriate
places (e.g.; clothing or floor) (Criterion A). Most often this is involuntary but occasionally may be intentional. The event must ocem at least once a month for at least 3 months (Cri terion B), and the chronological age of the child must be at least 4 years (or for children with developmental delays, a mental age of at least 4 years) (Criterion C). The fecal incontinence must not be due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition excep t through a mechanism involving cons tipation (Criterion D). When the passage of feces is involun tary ra ther than intentional, it is often related to constipation, impaction, and re tention with subsequent overfl ow. The constjpation may develop for p sychological reasons (e.g., anxie ty about defecating in a particular place or a more general pattern of anxious or oppositiona l behavior) leading to avoid
Encopresis
of the external sphincter or pelvic floor during straining for defecation. Dehydration associated with a febri le illness, hypothyroidism, or a medication side effect can also
induce cons tipation. O nce cons tipation has developed, it may be complicated by an anal fi ssure, painful defecation, and further feca l retention. The consis tency of the stool may vary. In some individ uals it may be of norma l or near-norma l consistency. It may be liquid in other individuals who have overflow incontinence secondary to fecal retention.
Subtypes
Encopresis is coded according to the subtype that characterizes the presentation: 787.6 With Constipa tion and Overflow [n continen ce, There is evidence of constipation on physical examination (i.e., the p resence of a large stool mass on abdominal or rectal examina tion) or a history of a stool frequency of less than three per week. Feces in overflow incontinence are characteristically (but not invariably) poorly formed, and leakage can be infrequent to continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed dwing toiletting, and the incontinence resoh'es after treatment of the constipation. 307.7 With out Constipation and Overflow Incontinence. ll,ere is no evid ence of constipation on physical examination or by h istory. Feces are likely to be o f normal form and consistency, and soiling is intermitten t. Feces may be deposited in a prominent location. This is usually associated w ith the presence of Oppositional Defiant Disorder or Conduct Disorder or may be the consequence of anal ma sturbation. Soilin g wi thou t constipation appears to be less common than soiling with constipation.
Preva lence
It is estimated that approximately 1% o f 5-year-olds have Encopresis, and the disor-
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Course
Encopresis is not diagnosed until a child has reached a chronologica l age of at least 4 years (or fo r children with d evelopmental delays, a menial age of at leas t 4 years). Inadequate, inconsistent toilet training and p sychosocial stress (e.g.; entering school
or the birth of a sibling) may be predisposing factors. Two types of course have been
described: a "primary" type in which the individual has never establis hed fecal continence, and a "secondary" type in which the disturbance develops after a period of established fecal continence. Encopresis can persist w ith intermittent exacerbations for years.
Differential Diagnosis
A diagnosis of Encopresis in the presence of a general medical condition is appropriate only if tJle mechanism involves functional cons tipation . Fecal incontinence related to other general medical conditions (e.g., chronic d iarrhea, spina bifida, anal s tenosis) would not warrant a DSM-IV diagnosis of Encopresis.
O. The behavior is not due exclusively to the direct physiolog ical effects of a substance (e.g., laxatives) or a general medical condition except th rough a mechanism involving constipation.
Code as follows:
787,6 307.7
With Constipation and Overflow Incontinence Without Constipation and Overflow Incontinence
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119
continence is expected (i .e., the chronological age of the child mus! be at leas t 5 years, or, for children with developmental delays, a mental age of at least 5 years) (Criterion C). The urinary incontinence is not due exclusively to the direct physiolog ica l effects of a substance (e.g., diuretics) o r a general medical condition (e.g., d iabetes, spina bifid a, a seiztue disorder) (C riterion D).
Subtypes
The situation in which the Enuresis occurs may be noted by one of the followin g subtypes: Nocturnal Only_ This is the most common subty pe and is defined as passage of tuine only dtuing nighttime sleep. The enuretic event typically OCCtuS during the first one-third of the nigh!. Occasionally the voiding takes place during the rapid eye movement (REM) stage of sleep, and the child may recall a dream that involved the act of urinating. Diurnal Only. This subtype is defined as the passage of tuine only durin g waking hours. Ditunal Entuesis is more common in females than in males and is WlConlffion after age9 years. Individuals w ith dhunal Enuresis can be divided into two gTOUpS. One group with "urge incontinence" has Enuresis characterized by sudden urge symptoms and detrusor instability on cystometry. Another g roup with "voiding pos tponement" consciously defer micturition tuges lmtil incontinence results, with the deferral sometimes due to a reluctance to use the toilet because of social anxiety or a preoccupation with school or play activity . Thisicltier group has a high rate of symptoms of dis ruptive behavior. The enuretic event most commonly occurs in the early afternoon on school days. Nocturnal and Diurnal This subty pe is defined as a combination of the two subtypes above.
\120
Prevalence
The p revalence of Enuresis is around 5%---10% among 5-year-olds, 3%-5% among 10}'ear-olds, and arOlmd 1% among individuals age 15 years or older.
Course
Two types of course o f Enuresis have been described: a "primary" type in which the individual has never established urinary continen ce, and a "secondary" type in which the disturbance develops after a period of established urinary continence. By definition, primary Enuresis begins at age 5 years. The most common time for the onset of secondary Enuresis is between the ages of 5 and 8 years, but it may occur at any time. After age 5 years, the ra le o f spontaneous remission is beh\'een 5% and 10% per year. Most children wilh the disorder become con tinent by adolescence, but in approxima tely 1% of cases the d isorder continues into ad ulthood .
Familial Pattern
Approximately 75% of all children w ith Enuresis have a first-degree biological relative who has had the disorder. The risk of Enuresis is five- to sevenfold grea ter in the offspring o f a parent who had a history of Enuresis. The concordance for the disord er is greater in monozygotic twins than in dizygotic twins. Although molecular genetic analyses have d etected lin ks to several chromosomes, no Significant associations between linkage to a chromosome in terval and type of enuresis have been identified.
121
D. The behavior is not due exclusively to t he direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).
Specify type;
Nocturnal Only Diurnal Only Nocturnal and Diurnal
309.21
Diagnostic Features
The essential fea ture of Separation Anxiety Disorder is excessive anxiety concerning separation from the home or from those to whom the person is attached (Criterion A). This anxiety is beyond that which is expected for the individual's developmenta] level. The d isturbance m ust last for a period of at least 4 weeks (Criterion B), begin before age 18 years (Criterion C), and cause clinically significant distress or impairment in social, academic (occupational), o r other important areas of functioning (Criterion D). The diagnosis is no t made if the anxiety occurs exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder or, in adolescents or adults, if it is better accoun ted for by Panic Disorder With Agoraphobia (Criterion E). Individuals with this disord er may experience recurrent excessive distress on separa tion from home or major attachment fi gures (Criterion A1). 'W hen separated from attach ment fi gures, they often need to know their whereabouts and need to stay in louch with them (e.g., by telephone caUs). Some individuals become extremely homesick and uncomfortable to the point of misery when away from home. They may yearn to retum home and be p reoccupied w ith reunion fantasi es. When separated
122
from major attachment figures, these individuals are often preoccupied with fea rs tha i accidents or illness will befall the attachment figures or themselves (Criterion A2). Child ren with this diso rder often express fear of being lost and never being reunited with their parents (Criterion A3). They a re often uncomfortable when tra" eiing independently away from the house or from other familia r areas and may avoid going places by themselves. They may be reluctant or refuse to attend school or camp. to visit or sleep a t friends' homes. or to go on errands (Criterion A4). These children may be unable to stay or go in a room by themselves and may display "clinging" behavior, staying close to and "shadowing" the parent a round the house or requiring someone to be with them w hen going to another room in the house (Criterion AS). Children with this disorder oflen have difficulty at bedtime a nd may insisllhal someone s tay with them unti l the}' fall asleep (Cri terion A6). During the night, the)' rna)' make their way to their parents' bed (or tha t of another significant person, such as a Sibling); if entry to the parental bedroom is barred, they may sleep outside the pare n ts' door. There may be nightmares whose content expresses the indiv idual's fears (e.g., des truction of the famil y tluough fire, murder, o r o ther catas trophe) (Cri terion A7). Physical complaints, such as s tomachaches, headaches, nausea, and vomiting are common when separation occurs or is anticipa ted (Cri lerion AS). Card iovascular symptoms such as palpitations, dizziness, and fee ling faint are rare in younger chilo dren but may occur in older indhiduals.
Specifier
Early O nset. This specifier may be u sed to indica te onset of the disorde r before age 6 years.
123
sistent over time, jus tify ing an additional diagnosis of Dysthymic Disorder or Major Depressive Disorder in some cases. The disord er may precede the development of Panic Disorder W ith Agoraphob ia. Comorbidity with other Anxiety Disorders may be common, especia lly in clinica l settings.
Prevalence
Sepa ration Anxiety Disorder is not uncommon; prevalence estimates average about 4% in children and yOlmg adolescents. Separation Anxiety Disorder decreases in prevalence from childllOOd through adolescence.
Course
Sep aration Anxiety Disorder may d evelop after some life s tress (e.g., the dea th of a relative or pet, an illness of the child or a relative, a change of schools, a move to a new neighborhood, or immigration). Onset may be as early as preschool age and may occur at an y time before age 18 years, b ut onset as late as adolescence is uncommon. Typically there are periods of exacerbation and remission. In some cases, both the afLxiety about possible separation and the avoidance of situations involving separation (e.g., goi.ng away to college) may persist for many years. However, the majority of children w ith Separation Anxiety Disorder are free of impairing Anxiety Disorders at extended follow-up .
Familial Pattern
Separation Anx iety Di sorder is more common in firs t-degree b iological relatives than in the general population and is relatively more frequent in children of mothers with Panic Disorder.
Differential Diagnosis
Separation anxiety can be an associa ted feature of Pervasive Developmental Disorders, Schizophrenia, or other Psychotic Disorders. If the symptoms of Sepa r.l tion Anxiety Disorder occu r exdusively during the course of one of these disorders, a separate diagnosis of Separation Anxiety Disorder is not given. Separation Anxiety Disorder is distinguished from Generalized Anxiety Disorder in tha t the anxiety predominantly concems separation from home and attachmen t figures. In child ren or adolescents with Separation Anxiety Disorder, threats of separation may lead to extreme anxiety and even a Panic Attack. In contrast to Panic Disorder, the anxiety concerns separation from attachment figures or from home rather than being incapacitated b y an unexpected Panic Attack. In adults, Separation Anxiety Disorder is rare and should not be given as an additional diagnosis if the separation fea rs are better accounted for by Ago raphobia in Panic Disorder With Agoraphobia or Agoraphobia Without History of Panic Disorder. Truancy is common in Conduct Disorder, but anxiety about separation is not responsible for school absences and the child usually stays away from , rather than returns to, the home. Some cases of school refusal, especiaUy in adolescence, are due to Social Phobia or Mood Disorders rather than separation anxiety. Children with Separation Anxiety Disorder may be oppositional in the context o f being forced to separate from attachment figu res. Oppositional Defiant Disorder should be diagnosed only if there is oppositiona l behavior at times other than at times of separation or when separation is anticipated . Similarly, children w ith Separation Anxiety Disorder may become depressed while being separated or in anticipation of separation. A Depressive Diso rder should be d iagnosed only if the depression occurs at other times. Unlike the hallucinations in Psychotic Disorders, the unusual perceptual experiences in Separation Anxiety Disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the p resence of an attaclunent figure. Clinical judgment must be used in distinguishin g developmentally appropriate levels of separation anxiety from the clinically significant concerns about separation seen in Sepa ration Anxiety Disorder.
313.23
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D. The disturbance causes clinically significant distress or impairment in social, academic (occupationa l), or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Develop mental Disorder, Schizophren ia, or other Psychotic Disorder and, in adolescents and adu lts, is not better accounted for by Panic Disorder Wit h Agoraphobia.
Specify if:
126
tive Mutism should not be diagnosed if the individual 's failure to speak is due solely to a lack of knowledge of, or comfort with, the spoken language required in the social situation (Criterion 0 ). It is also not diagnosed if the disturbance is better accounted for by embarrassment related to having a Comrnlmication Disorder (e.g., Stuttering) or if it occurs exclusively during a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder (Criterion E). Instead of communicating by standard verbalization, children w ith thi s disorder may communicate by ges tures, nodding or shaking the head, or pulling or pushing, or, in some cases, by monosyllabic, short, or monotone utterances, or in an altered voice.
Prevalence
Selective Mutism is apparently rare and is found in fewer than 1% of individuals seen in mental health settings.
Course
Onset of Selective Mutism is usually before age 5 years, bu t the disturbance may not come to clinical aUention until entry into school. The degree of persistence of the disorder is variable. It may persist for only a few months or may continue for several years. In some cases, particularly in those with severe Social Phobia, anxiety symptoms may become chronic.
313.89
127
Differential Diagnosis
Selective Mutism shou ld be distinguished from speech dis turbances that are better accounted for by a Communication Disorder, such as Phonological Disorder, Expressive language Disorder, Mixed Receptive-Expressive Language Disorder, or Stuttering. Unlike Selective Mu tism, the speech disturbance in these conditions is not restricted to a specific social situation. Child ren in families who have immigrated to a country where a different lan guage is sp oken may rehlse to speak the new language because of lack of knowledge of the language. U comprehension o f the new language is adequate, but refusal to speak persis ts, a diagnosis of Selective Mutism may be warranted . Individuals w ith a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder, or severe Mental Retardation may have problems in social com munication and be unable to speak appropriately in sodal situations. In contras t, Selective Mutism should only be diagnosed in a child who has an established capacity to speak in some social situations (e.g., typically at home). The social anxiety and social avoidance in Social Phobia may be associated with Selective Mutism. In such cases, both diagnoses may be given.
D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language requ ired in t he social situation. E. The disturbance is not better accou nted for by a Commu nication Disorder (e.g., Stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schi zophren ia, or other Psychot ic Disorder.
313.89
Diagnostic Features
The essen tial feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in mos t contexts that beg ins before age 5 years and is associated with grossly path ological care (Criterion A). There are two types of p resentations. In the Inhibited Type, the ch ild persis tently fails to initiate and to respond to mos t social interactions in a developmentally appropriate way. The
Diso rde rs Usua lly First Diagnose d in Infancy. Chi ldh ood. o r Ado lesce nce
child shows a pattern of excessively inhibited, hyperv igilant, or highly ambivalent res ponses (e.g., fro zen watch fulness, resistance to comfort. or a m ixture of approach and avoidance) (Criterion Al ). In the Disinhibited Ty pe, there is il pattern of diffuse attachments. The child exhibits indiscrim inate sociab ility o r a lack of selectivity in the choice of attachmen t figures (Criterion A2). TI,e d isturbance is not accounted for solely by d evelopmental delay (e.g., as in Mental Retardation) and d oes not meet criteria for Pervash 'e Developmental Disorder (C riterion B). By d efinition , the condition is associated w ith grossly pathological care that may take the form of persisten t d isregard o f the child 's basic emotional needs for comfort, stimula tion, and affection (Criterion C I); persistent disregard of the child 's basic physical need s (Cri terion C2); or rep eated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent chan ges in foster care) (Criterion C3). The pathological care is presumed to be responsible for the disturbed social relatedness (C riterion D).
Subtypes
The predominant type o f disturbance in social relatedness may be indica ted by sp ecifying one of the following subtyp es for Reacti ve Attachment Disorder: Inhi b ited Ty pe. In this su btype, the predominant d isturbance in social relatedness is the persistent failure to initiate and to respond to most social interactions in a d evelop mentally appropria te W,l y. Di sinhib ited Typ e. This subtype is used if the p redominan t distu rbance in social relatedness is ind iscriminate sociab ility or a lack of selectivity in the choice of attach men t figures.
313.89
129
Prevalence
Epidemiological data are limited, but Reactive Attachment Disorder appears to be very unconlmon.
Co urse
The onset of Reactive Attach ment Disorder is usually in the first several years of life and, by d efinition, begins before age 5 years. The course appears to vMy depending on individual factors in ch ild and caregivers, the severity and duration of associated psychosocial depriva tion, and the natu re of intervention . Considerable improvement or rem ission may occur if an appropriately supportive environment is provided. Otherwise, the disord er follows a continuous cou rse. Indiscriminate sociability may persist even after the child ha s developed selective attachments.
Differential Diagnosis
In Me ntal Retardation, appropriate a ttachments to caregivers usually develop consistent with the child's general d evelopmental level, and these attachments are dearly present by the time a child has a menta l age of 10 months. However, some in fants and young ch ildren with Severe Mental Retardation may p resent particular problems for caregivers and exhibit sy mptoms characteri stic of Reactive Attachment Disorder. Reactive Attachment Disorder should be diagnosed only if it is dear that the characteristic p roblems in formati on of selective attachments are not a function of the retarda tion. Reactive Attachment Disorder must be differentiated from Autistic D isorder and other Pervasive Developmental Disorders. In the Pervasive Developmental Disorders, selective attachmen ts either fa il to d evelop or are highly deviant, bu t this usually occurs in the fa ce of a reason ably supportive psychosocial environm ent. Autistic Disorder an d other Pervasive Developmental Disorders are also characterized by the presence o f a qualitative impairmen t in communication and restricted, repetitive, and stereotyped patterns of behavior. Reactive Attachment Disord er is not diagnosed if the criteria are met fo r a Pervasive Developmental Disorder. The Inhibited Type of Reactive Attachmen t Disorder mllst be d istinguished from Social Phobia. In Socia l Phobia, the social inhib ition is apparent in socia l settings o r in anticipation of socia l encounters but does not occur with familiar caregivers in familiar settings. Socially deviant behavior in Reactive Attachment Disorder, including inhibition, is apparent across socia l contexts. The Disinhibited T}'Pe must be disting u ished from the impuls ive or hyperactive behavio r characteristic of Attention-Deficit/Hyperactivity Disorder. In contrast to Attention-Deficit / Hyp eractivity Disorder, the disinhibited behavior in Reactive Attachment Disorder is characteristically associated with being overly familia r with or seeking comfort from an unfamiliar ad ult caregiver rather than with generally impulsive behavior. Reactive Attach ment Disorder sho uld also be differentia ted from Disrup tive Beha\' ior Disorders such as Conduct Diso rd er and Oppositional Defiant Disorder. The term "affectionless psychopath" has been used to describe children w ho were
130
raised in settings thai limited opportunities for the child to d evelop selective attach ments (e.g., institutions) and who exhibited a pattern of antisocial and aggressive beha vior, inability to form lasting relationships with adults, and miscellaneous symptoms slich as enuresis and s tereotypies. Nevertheless, no direct link between Reactive Attach ment Disorder and "a ffectionless psychopathy" has been established.
Disturbances of attachment in the early years may increase the risk for antisocial behaviors in later childhood and adolescence, but antisocial behaviors are not necessarily signs of Reactive Attachment Disorder. Grossly pa thogenic care is a defining feature of Reactive Attachment Disorder. An additional notation of Child Abuse, Child Neglect, or Parent-Child Relational Problem may be warranted. When grossly pathogenic care docs not result in marked disturbances in social relatedness, Child Neglect or Parent-Child Relational Problem may be noted rather than Reactive Attachment Disorder.
Diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood
A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2): (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambiva lent and contradictory responses (e .g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) (2) diffuse attachments as manifest by indiscriminate sociabi lity with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) B. The disturbance in Criterion A is not accounted for solely by developmenta l delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.
C. Pathogenic care as evidenced by at least one of the following:
(1) persistent disregard of the chi ld's basic emotional needs for comfort, stimulation, and affection (2) persistent disregard of the child's basic physical needs (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequ e nt changes in foster care) D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
Specify type:
Inhibited Type: if Criterion A 1 predominates in the clinica l presentation Disinhibited Type : if Criterion A2 predominates in the clinical presentation
307.3 Ste re otypic Movement Disord e r (fo rmerly Ste re otypy! Habit Disord er)
Speci f iers
The clin ician m ay sped1y With Self-I njurious Behavio r if the behavior resu lts in bodily damage that requires specific treatment (or that would resu lt in bodily damage if p rotective measures were n ot used).
132
drome, Down syndrome, de Lange syndrome, and especially Lesch-Nyhan syndrome, which is characterized by severe self-biting).
Associated laboratory findings. If there is self-injury, the laboratory findings will refl ect its nature and se ve rity (e.g., anemia may be p resent if the re is a chronic blood
due to eye gouging or traumatic cataract, and fractures or deformed bones). In less
severe cases, there may be a dlronic skin irri tation o r calluses from biting, pinching, scratching, or sa liva smearing.
Preva le nce
There is limited in formation on the prevalence of Stereotypic Movement Disorder. The estimates o f prevalence of self-injuriOUS behaviors in indi viduals w ith Mental Retardation vary from 2% and 3% in child ren and adolescen ts lhring in the community to approximately 25% in adults with severe or pro fo und Men tal Retardation living in institutions.
Course
There is no typica l age at onset or pattern of onset for Stereot),pic Movement Disorder. The onset may follo w a stressful environmental even t. In nonverbal individuals with Severe Mental Retarda tion, stereotypic m ovements may be triggered by a painhli general med ical condition (e.g., a middle ear infection leading to head banging). The stereotypic movements often pea k in adolescence and then may g radually decline. However, esp ecially in individuals with Severe or Profound Mental Retardation, the movements may p ersist for years. The focus of these behaviors oft en changes (e.g., a person may engage in hand bi ting that may then subside and head hitting may emerge).
ic Movemen t Disorder is not diagnosed if the s tereotypies aTe better accounted for by a Pervas ive Developmental Disorder. Compuls ions in ObsessiveCom pulsive Disorder are generaUy more complex and ritualistic and are performed in response to an obsession or according to rules that must be applied rig idly. Differentiating the com plex movemen ts charncteristic of Stereotypic Movement Disorder from s imple tics (e.g., eye blinking) is relntively straightforward. HoweVer, differentiating Stereo typic Movement Disorder from co mpl ex molor tics ca n be quile d iffi cult, given the similarities be h\'een the h\'o in terms of intentionality, rhythmicity, and drivenness. In Trichotillomania, by definition, the repetitive behavior is limited to hair pulling. The self-induced injuries in Stereotypic Movement Disorder should be di stinguished from Factitious Disorder With Predomin antly Physical Signs an d Symptoms, in which the motivation of the self-injury is to assume the s ick role. Self-mutilation associated with certain Psychoti c Disord ers and Person ality Disord ers is p remeditated, complex, and sporadic and has a meaning for the individual within the context of the underly ing, severe mental disorder (e.g., is the resu lt of delus ional thinking). Involunta.ry movements associated w ith neuro logical conditions (such as Huntington's disease) usually follow a typical pattern, and the signs and symptoms of the neurological condition are present. Tard ive D yskines ia us ually results from chronic neuroleptic use and consis ts of characteris tic orofadal dyskinesias or, less commonly, irregular truncal o r limb movements. In add ition, these ty pes of movements do not result in direct self-injury. Developm entall y appropriate self-stimulatory behaviors in young children (e.g., thumb s ucking, rocki ng, and head banging) a re us ually self-limited and rarely result in tissue damage requiring treahnent. Self-directed behaviors in individu als with sensory deficits (e.g., blindness) a rc repetitive and s tereotyped but usually do not result in d ysfunction or in self-injury. Many people engage in repetitive b ehaviors for variou s reasons (practicing to improve a motor skill, cult urally sanctioned practices). In con trast to Stereotypic Movemen t Disorder, these behaviors do not interfere w ith norma l activities nor do they result in self-injury .
Repetitive, seeming ly d riven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing o f objects, se lf-bit ing, pick ing at skin o r bodily orifi ces, hitting own body).
B. The behavior markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment (or would result in an injury if preventive measures were not used).
C. If Menta l Retardation is present, the st ereotypic or self-injurious behavior is o f suHicient severity to become a focus of treatment.
D. The behavior is not better accounted for by a compulsion (as in Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotypy that is part of a Pervasive Developmental Disorder, o r hair pulling (as in Trichot illomania).
E. The behavior is not due to the direct physiolog ical eHects of a su bstance or a general medical condition.
F. The behavior persists for 4 weeks or longer.
Specify if:
With Self-Injurious Behavior: if t he behavior results in bod ily damage that requires specific treatment (or that would result in bodily damage if protective measures were not used)
section includes Delirium, Dementia, Amnestic Disorders, and Cognitive Disorder Not O thenvise Specified . The predominant disturbance is iI clinically signi ficant deficit in cognition that represents a significant change from a p revious level of fun ctioning. For each disorder in this section, the etiology is either a general medical condition (a llhough the specific general medical condition may not be identifiable) or a substance (i.e., a drug of abuse, med ication, or toxin), or a combination of these fac tors. Ln DSM-ITI-R, these di sorders w ere placed in a section titled "Organic Mental Syndromes and Disorders," The term orgnll;c //II!/lfal disorder is no longer used in DSM-IV because it incorrectly implies that "nanorganic" mental disorders do not have a bio logica l basis. In DSMIV, disorders formerly ca lled "organic mental disorders" have been grou ped into three sections: 1) Delirium, Dementia, and Amnestic and Other Cognitive Disorders; 2} ~'I en ta l Disorders Due to a General Medical Condition; and 3} Substance--Related Disorders. A delirium is characterized by a disturbance of consciou sn ess and a change in cog nition that develop over a short period of time. The disorders included in the "Delir ium" section are listed according to presumed etiology: Delirium Due to a General Medical Condition, Substancelnduced Delirium (i.e., due to a drug of abuse, a med ication, or toxin exposure), Delirium Due to Multiple Etiologies, or Delirium Not O th em'ise Specified (if the etiology is indeterminate). A dementia is characterized by multiple cognitive defici ts that include impairment in memory. The dementias are also listed according to presumed etiology: Dementia of the Alzheimer's Type, Vascular Dementia, Dementia Due to O ther General Medi ca l Conditions (e.g., human immunodeficiency virus (HTV] disease, head trauma, Parkinson's disease, Hunting ton 's disease), Substancelnduced Persisting Dementia (i.e., due to a drug of abuse, a medication, or toxin exposure), Demen tia Due to Multiple Etiologies, or Dementia Not Otherw ise Specified (i f the etiology is indeter minate). An amnestic disorder is characterized by memory impairment in the absence of other significant accompanying cognitive impairments. The disorders in the" Amn es tic Disorders" section also are listed according to presumed etiology: Amnestic Dis order Due to a General Medica l Condition, Substance lnduced Persisting Amnestic Disorder, or Amnestic Disorder Not Otherwise Specified .
ThiS
135
136
Cognitive Disorder Not Otherwise Specified is for presentations that a re characterized by cognitive dyshmction presumed to be du e to either a general medica l condition or substance use tha t do not meet criteria for any of the disord ers lis ted elsewhere in this scction. Introd uctory text is provided that discusses the genera] features for each group of disorders, rega rdless of e tiology. This is follo wed by text and criteria for each disorder with specific etiol ogy.
Delirium
The disorders in the "Delirium " section share a common symptom presentation of a disturbance in consci ousness and cognition, but are d ifferentiated based on etiology: Delirium Due to a Ge neral Medical Cond ition, Substance-Induced Delirium (induding medication side effects), and Delirium Due to Multiple Etiologies. In addition, Delirium Not Othenvise Specified is induded in this section for presentations in which the clinician is unable to determine a specific etiology for the d eli rium.
Diagnostic Features
The essential feature of a delirium is a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a p reexisting or evolving dementia. The disturbance develops over a short period of time, usually hours to days, and tends to fl uctuate during the course of the day. There is evidence from the his tory, physical examination, or laboratory tests tha t the delirium is a direct physiological consequence of a general medical condition, Substance Intoxication or Withdrawal, u se of a medication, or toxin exposure, or a combination of these factors. The dis turbance in consciousness is manifeste d by a reduced clarity of awareness of the environment. The ability to focus, sustain, or shift attention is impaired (Criterion A). Ques tions must be repeated because the individual's attention wanders, or the individual may perseverate w ith an answer to a previous question rather than appropriately s hift attention. The person is easily dis tracted by irrelevant stimuli. Because of these problems, it may be difficult (or impossible) to engage the person in conversation. There is an accompanying change in cognition (which may include memory impaimlent, disorientation, or lang uage dis turbance) o r d evelopment of a perceptual distu rbance (Criterion B). Memory impairment is most commonly evident in rffent memory and can be tested by asking the person to remember several unrelated objects or a brief sentence, and then to repeat them after a few minutes of dis traction . Disorientation is u sually manifested by the indiv idual's being disoriented to time (e.g., thinking it is morning in the middle of the night) or being disoriented to place (e.g., thinking he or s he is home rather than in a hospital). In mild delirium, disorientation to time may be the first symptom to appear. Disorientation to self is less common. Speedl or language disturbances may be evident as d ysarthria (i.e., the impaired ability to articulate), d ysnomia (i.e., the impaired ability to name objffts),
Delirium
137
dysgraphia (i.e., the impaired ability to write), or even aphasia. In some cases, speech is rambliJlg and irrelevant, in o thers pressured and incoherent, with unpredictable switching from subject to subject. It may be difficult for the clinician to assess for changes in cognitive fun ction because the individual may be inattentive and incoher ent. Under these circumstances, it is helpful to review carefull y the individual's history and to obtain information from other informants, particularly family members. Perceptual d isturbances may include misin terpretations, illusions, or hallucina tions. For example, the banging of a d oor may be mistaken for a gunshot (misinter pretation); the folds of the bedclothes may appear to be animate objects (i llusion); or the person may "see" a g roup of people hovering o\'er the bed when no one is actu ally there (hallucination). Although sensory misp erceptions are most commonly vi sua!, they may occur in other sensory modalities as well, such as aud itory, tactile, gustatory, and olfactory. Misperceptions range from simple and uniform to highly complex. The individual may have a delusional conviction of the reality o f the hallu dnations and exhibit emotional and behav ioral responses consistent with their content. The disturbance d evelops over a short period of time and tends to flu ctuate during the course of the day (Criterion C) . For example, during morning hospital rounds, the person may be coherent and coopera tive, but at night might insist on pulling out in travenous lines and going home to parents who died years ago.
Delirium. Dement ia. and Amnest ic a nd Other Cog nitive Disorders are especially prevalent at night and under conditions in wh ich stimulation and en vironmental cues are lacking. Impaired judgment may interfere with proper medical treatment. Depending on the etiology. delirium can be associated with a number of nonspecific neurological abnormalities. such as tremor. myoclonus, asterixis, and refl ex o r muscle tone changes. In addition to labora tory findings that are characteristic of associa ted or etiological general medical conditions (or intoxication or withdrawal stales), the EEG is typically abnormal, showing generalized slowing. Fast activity is occasionall}' found, for example. in some cases of Alcohol Withdrawal Delirium.
Pre valence
The point prevalence of delirium in the general population is 0.4% in adults age 18 years and older and 1.1% in those age 55 and older. The point p revalence of delirium in the hospitalized medically ill ranges from 10% to 30%. In the hospitalized elderly. /0-40% may be about 100/0-15% are reported to exhibit d elirium on ad m ission. and 10 diagnosed with delirium while in the hospital. Up to 60% of nursing home residents age 75 years and older may be delirious at any g iven time. As many as 25% of hospi talized cancer patients and 30%- 40% of hospitalized AIDS patients develop delirium during their hosp italization. Up to 80% of those w ith tenninal illness d evelop d eliri urn near death. The ra te of delirium in these populations depends greatly on the na ture of their associated general medical conditions and surgical procedures.
Course
The symptoms of delirium usually develop over hours to days, although in some individuals they may begin abruptly (e.g . after a head injury). More typicali}', prod romal symptoms. such as restlessness. anxiety, irritability, d isorientation. distracti
Delirium
139 \
bili ty, or sleep dis turbance, prog ress to fuU ~blown delirium within a 1- to 3-day period . The delirium may resolve in a few hours to days, or symptoms may persist for weeks to months, particularl), in elderly individuals and individuals w ith coexis ting dementia. If the underlying etiologica l fac tor is promptly corrected or is selflimited, recovery is more likely to be complete and more rapid . lndividuals with beller premorbid cognitive and physical functioning have better recovery from delirium . Those with previous episodes of delirium may be at increased ris k for recurrent symptoms. While the majority of individuals have a full recover}', delirium may progress to stupor, coma, seizures, or death, particularly if the underly ing cause is untreated. Full recovery is less likely in the elderly, with estimated rates of full recovery by the time of hospital discharge varying from 4% to 40%. Many symptoms w ill not have resolved by 3-6 months after discharge. Persistent cogniti\'e deficits are also common in elderly indi viduals recovering from delirium, although s uch deficits may be due to preexisting dementia that was not full y appreciated. Being admitted to a hospital from home (as opposed to from an institutional setting) is related to a higher rate of improvement in mental s tate. Delirium in the medically ill is associated w ith significant morbidity. Medically ill individuals with delirium, particularly the elder!y, have Significantly increased ris k of medical complications, s uch as pneumonia and decubitus ulcers, resulting in l ong~ er duration of hospital stays. Delirium is also associated with increased functional decline and risk of institutional placemenl. Hospitalized patients 65 yea rs or older with delirium have three times the risk of nursing home placement and about three times the functional decline as hospitalized patients without delirium at both discharge and 3 months pos tdiscllarge. In postoperative patients, delirium is a harbinger o f limited recovery and poor l o ng~ term outcome and is often associa ted with increased risk for postoperative complications, longer postoperative recuperation periods, longer hos~ pi tal stays, and increased long-tenn disability. Deli rium in the medically iU is a Iso associa ted with increased mortali ty. Elderly individuals who develop delirium during a hospitalization may have up to a 200/..-75% chance of d ying during that hospitalization . Patients who develop deliriunl during a hospitalization also have a very high death rate during the months following discharge. Up to 15% of elderly patients with delirium die within a I -mon th period and up to 25% die w ithin a 6-month period after discharge. Other risk factors, such as type of illness, illness severity, preex is ting cogniti ve impairment, and age, contribute significantly to th is association. Patients w ith malignancies and delirium have a partic~ ularly high mortality rate both in~hospita l and after d ischarge co mpared with patients w ith malignancies w ho do not also have delirium.
1 140
In delirium the onset of symptoms is much more rapid (i.e., usually over hours to days), whereas in dementia the onset is typically more gradual or insidious. Delirium
symp tom severity characteristically fl uctuates during a 24-hour period, whereas dementia symptom severity generally does not. When symptoms of a delirium are present, information h om family members, other caretakers, or medical records may
be helpful in d etermining whether the sym p toms o f a dementia were preexis ting. Coding of a delirium superimposed on the different types of d ementias is discussed under " Reco rd ing Procedures" for each type of deli rium. The presumed etiology determines the s pecific deli rium d iagnosis (text and criteria for each d eli rium d iagnosis are provided separately later in this section). If it is judged that the d elirium is a consequence o f the direct p hysiological effects of a general medica l condition, then Delirium Due to a General Medical Condition is diagnosed . If the d elirium results h om the d irect phYSiological effects of a d rug of abuse, then Substan ce Intoxication Delirium or Su bstance Withdrawal Delirium is d iagnosed , d epending on whether the d elirium occurred in associa tion w ith Substance Intoxication or Substance Withdrawal.lf the delirium resu lts fro m medication use or toxin exp osure, then Substance-Indu ced Delirium is d iagnosed. It is not uncommon for the delirium to be due to both a general medical condition and substance (including medication) use. This m ay be seen, for example, in an eld erly individual w ith a serio us general medical cond ition that is being treated w ith multiple medications. \hen there is more than one etiology (e.g., both a substance and a general medical cond ition), Delirium Due to Multiple Etiologies is d iagnosed . If it is not possible to establish a sp ecific etiology (i.e., substance induced or due to a general medical condition), Delirium Not Othenvise Specified is diagnosed . The diagnosis of Substance Intoxica tion Delirium o r Substance Withdrawal Deliriwn is made instead o f Substance In toxication or Substance Withdrawal on ly if the symp toms of the delirium are in excess of those usually associated w ith the intoxication or withdrawal syndrome and are sufficiently severe to warrant indep endentclinical attention. Even in individuals with obvio us signs of intoxication or w ithd rawal, other p ossible causes of the delirium (i.e., Delirium Due to a General Medical Condition) must not be overlooked. For example, a head injury that occurs as a result o f falls o r figh ting during intoxication may be resp onsible for the d elirium. Deli riwn that is characteri zed by vivid ha llucina tions, d elusions, language disturbances, and agitation must be d istinguished from Brief Psychotic Disorder, Schizophrenia, Schizophreniform Disorder, and oth er Psychotic Disorders, as well as from Mood Disorders With Psychotic Features. In d elirium, the p sychotic symp toms are frag mented and u nsystematized. Delirium that is ch aracterized by mood changes and anxiety must also be d istinguished from Mood Disorders and Anxiety Disorders. Finally, delirium associated with fear, anxiety, and dissociative symptoms such as d epersonalization must be distinguished from Acu te Stress Diso rder, whkh is precip itated by exposure to a severely traumatic event. Psychotic, mood , anxiety, and d.issocia tive symptoms associated with delirium typically flu ctuate, occur in the context of a red uced ability to appropriately m aintain and shift attention, and are usually associated w ith EEG abnormalities. There is o ften memory impairmen t and disorientatio n in d elirium, but generally not in these other disorders. Finally, in delirium, the person generally shows evidence of an underlyin g general med ical condition, Substance intoxication or Withdrawal, o r medication u se.
293.0
141
Delirium must be distinguished from Malingering and from Factitiou s Disorder. This distinction is made based on the often atypical presentation in Malingering and Factitious Disorder and the absence of a general medical condition or s ubstance that is etiologically related to the apparent cognitive d isturbance. Individuals may presen t with some but not all symptoms of delirium. Subsyndroma l presentations need to be carefully assessed because they may be harbingers of a full -blown delirium or may signal an as yet undiagnosed underlying general medical condition . Such presentations should be coded as Cogn itive Disorde r Not O then vise Specified.
cian should note both the delirium and the identified general medical condition judged to be causing the disturbance on Axis I (e.g., 293.0 Delirium Due to Hypoglycemia). The ICD--9-CM code for the general medical condition shou ld also be noted on Axis ill (e.g., 251.2 hypog lycemia.) (See Appendix G for a list of selected ICD-9-CM d iagnostic codes for general medical conditions.) When the delirium is superimposed on a preexisting dementia, both diagnoses should be made (e.g., 294.11 Dementia of the Alzheimer's Type, With Behavioral Disturbance, and 293.0 Delirium Due to Hyponatremia). Since Alzheimer's disease is not an established etiology for delirium but only a risk factor, the etiology of any delirium superimposed on Alzheimer's disease must be determined. Because of ICD-9-CM coding requirements, delirium superimposed on Vascular Dementia is noted by coding the appropriate subtype of the dementia (e.g., 290.41 Vascular Dementia, With Delirium). In situations in which it is unclear whether the cognitive deficits are due to delirium or to dementia, it may be useful to make a provisional diagnosis of delirium and observe the person ca refully while continuing efforts to identify the nature of the disturbance.
143
Diagnostic criteria for 293.0 Delirium Due to [Indicate the General Medical Condition]
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with redu ced abil ity to focus, sust ain, or shift attention . B. A cha nge in cognition (such as memory deficit, disori entation, language disturbance) or the development of a perceptual disturbance t hat is not better account ed for by a preexisti ng, established, or evolvi ng dementia .
e.
The disturbance develops over a short period of time (usually hours to days) and tends to f luctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
Coding note: If delirium is superimposed on a preexisting Vascular Dementia, indicate the deli rium by coding 290.41 Vascular Dementia, With Delirium. Coding note: Include the name of the general medical condition on Axis I, e.g., 293.0 Deli rium Due to Hepatic Encephalopathy; also code the general medical condition on Axis III (see Appendix G for codes) .
Substance-Induced Delirium
Diagnostic and Associated Featu res
The descriptive features of Substance-lnduced Deli rium (Criteria A-C) are discussed on pp. 136-137. In addition, to diagnose Substance-Induced Delirium, there must be evidence from the history, physical examination, or laboratory findings of Substance In toxication or ' ''' ithdrawal, m edication side effects, or toxin exposure judged to be etiolog ically related to the delirium (Criterion D). A d elirium that occurs during Substance intoxication is diagnosed as Substance Intoxication Delirium, and a delirium tha t occurs during Substance Withdrawal is d iagnosed as Substance Withdrawal Delirium. A delirium that is associated with medication sid e effects or toxin exposu re is diagnosed as Substance-Induced Delirium (see criteria set for Substance Intoxication Delirium, p. 145). Delirium tha t occurs during Substance Intoxication usually arises within minutes to hours after taking relati vely high doses of certain drugs such as cannabis, cocaine, and hallUCinogens. However, onset can also be delayed for some substances that can accumulate over time because they ha ve long half-lives (e.g., diazepam). Usually the delirium resolves as the intoxication ends or w ithin a few hours to days. However, the duration may be longer after intoxication with phencyclidine and might persist for longer periods for individuals w ith brain damage, in the elderly, and in individuals ta king combinations of substan ces. The time between taking a substance and onset of intoxication Delirium may be shorter in individuals having p oor clearance (e.g., due to renal or hepatic d isease).
Deli r ium. Dementia. and Amnestic and Ot her Cog nitive Disorders
Delirium that is associated wi th Substance Withdrawa l develops as tissue and fluid concentrations of the substance d ecrease after reduction or termination of sustained. usually high-dose use of alcohol or sedative. hypnotic. or anxiolytic d rugs. In indiv idua ls haV ing poor cleara nce, experiencing drug interactions, or taking combinations of substances. Substance Withdrawal Delirium can occur after the reduction or termination of lower doses. The duration of the delirium tends to va ry with the half-life of the substance invol ved: longer-acting substances usually are associa ted with more protracted withdrawal. Substance Withdrawal Delirium may continue for only a few hou rs or may persist for as long as 2-4 weeks. Thi s diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance \<\Iithdrawal only when the cognitive symptoms are in excess of those usua lly associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently se\'ere to warrant independent clinical attention . For a more detailed discussion of the fearures associa ted wilh Substance-Rela ted Disorders, see p. 191.
Substance-Induced Delirium
145
sive agenls, lithium, mu scle relaxants, and psychotropic m edications w ith anticholinergic s ide e ffects. Toxins reported to cause delirium include o rganophosphate (an ticholinesterase), insecticides, carbon monoxide, and volatile subs tances s uch as fuel or organic solvents.
B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted fo r by a preexisting, established, o r evolving dementia.
e.
The disturbance develops over a short pe riod of time (usually hours to days) and tends to fluctuate during the course of the da y.
D. There is evidence fro m the history, physica l examination, or labo ratory findings of either (1) o r (2):
(1) the symptoms in Criteria A and B developed during Substance Intoxication
(2) medication use is etiologically related to the disturbance Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the cognitive symptoms a re in excess of those usually associated with the intoxication syndrome a nd when the sympt oms are sufficiently severe t o warrant independent cl inical attention. Note : The diagnosis should be recorded as Substance-Ind uced Delirium if related to medication use. Refer to Appendix G for E-codes indicating specific med icatio ns.
Code [Specific Subst ance j lntoxication Delirium:
(29 1.0 Alcohol; 292.8 1 Amphetamine [or Amphet amine-like Substance]; 292.81 Cannabis; 292.8 1 Cocaine; 292.8 1 Hallucinog e n; 292.8 1 Inhalant; 292 .81 Opioid; 292.B1 Phencyclidine [or Phencyclidine-like Substance]; 292.81 Sedative, Hypnotic, o r Anxiolytic; 292.8 1 Other [o r Unknown] Substance [e.g., cimetidine, digita lis, benztropine])
146
or the development of a perceptual disturbance that is not better accounted fo r by a preexisting, established. or evolving dementia.
e.
The disturbance develops over a short period of time (usually hours to days) and
the symptoms in Criteria A and 8 developed during, or shortly after, a withdrawal syndrome. Note: This diagnosiS should be made instead of a diagnosis of Substance Withdrawal only when the cognitive symptoms are in excess of those usually associated with the with drawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
Code [Specific Substance] Withdrawal Delirium:
(291.0 Alcohol; 292.8 1 Sedative, Hypnotic, or Anxiolytic; 292.81 Other [or Unknown] Substance)
780.09
147 1
B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
C. The disturbance develops over a short period of time (usua lly hours to days) and tends to fluctuate during the course of the day.
D. There is evidence from the history, phySical examination, or laboratory findings that the delirium has more than one etiology (e.g ., more than one etiological general medical cond ition, a general medical condition plus Substance Intoxication or medication side effect). Coding note: Use multiple codes reflecting specific delirium and specific etiologies, e.g., 293.0 Delirium Due to Vira l Encephalitis; 291.0 Alcohol Withdrawal Delirium .
780.09
This category should be used to diagnose a delirium that does not meet criteria for any of the specific types of delirium described in this section. Examples include
l. A clinical presentation of delirium that is sllspected to be due to a general med-
ical condition or substance u se but for which there is insufficient evidence to establish a specific etiology 2. Delirium due to causes not listed in this section (e.g., sensory deprivation)
Dementia
The disorders in the "Dementia" section are characterized by the development of multiple cognitive deficits (including memory impairment) that are due to the dired physiological effects of a general medical condition, to the persisting effects of a substance, or to multiple etiologies (e.g., the combined effects of cerebrovascular disease and Alzheimer's disease). The disorders in this section share a conunon symptom presentation bu t are differentiated based on etiology . The diagnostic features lis ted in the next section pertain to Dementia of the Alzheimer's Type, Vascular Dementia, Dementia Due to HIV Disease, Dementia Due to Head Trauma, Dementia Due to Parkinson's Disease, Dementia Du e to Huntington's Disease, Dementia Due to Pick's Disease, Dementia Due to Creutzfeldt-Jakob Disease, Dementia Due to Other General Medical Conditions, Substance-Induced Persisting Dementia, and De-
148
mentia D ue to Multiple Etiologies. In addition, Demen tia Not Oth e rwise Specified is included in this section for presenta tions in which the clinician is unable to determine a specific etiology for the multiple cognitive deficits.
Di ag nosti c Features
TIle essential feature of a dementia is the developmen t of multiple cognitive deficits
that incl ude memory impairme nt and at least onc of the following cogni tive dis tur-
bances: aphasia, apraxia, agnosia, or a disturbance in executive functioning. The cognitive deficits must be sufficiently severe to cause impairment in occupational or social functioning and must represent a decline from a previously higher level of
fun ctioning. A diagnosis of a dementia should not be made if the cognitive deficits occu r exclusively during the course of a delirium. However, a dementia and a delirium may both be diagnosed if the demen tia is present at times when the deliriu m is nol present. Dementia may be etiologically related to a general medical condition, to the persisting effects of substance u se (including toxin exposure), or to a combination of these factors. Memory impairment is required to make the diagnosis of a dementia and is a prominent early symptom (Criterion AI). Individuals w ith dementia become impaired in their ability to learn new material, or they forget previously learned material. Most individuals with d ementia have both forms of memory impairment, although it is sometimes difficult to demonstrate the loss of previously learned material early in the course of the disorder. They may lose val uables like wallets and keys, fo rget food cooking on the s tove, and become lost in unfamiliar neighborhoods. In advanced stages of dementia, memory impairment is so severe that the person forg ets his or her occupation, schooling, birthday, family members, and sometimes evcn name. Memory may be formally tested. by asking the person to regis ter, retain, recall, and recognize informa tion. The ability to learn new information may be assessed by asking the individual to learn a list of words. The individual is requested to repeat the words (registration). to recall the informa tion after a dela}' of severa l minutes (retention, recall), and to recognize the words from a multiple list (recognition). Individuals w ith d iffi culty learning new informa tion are not helped by clues or prompts (e.g., multip le-choice questions) because they did not learn the material initially . In contrast, individuals with primarily retrieval defici ts can be helped by clues and prompts becau se their impairment is in the ability to access their memories. Remote memory may be tested by as king the individual to recall personal information or past material that the individual found of interest (e.g., politics, sports, entertainment). It is also useful to determine (from the individual and informants) the impact o f th e memory d isturbances on the ind iv idua l's func tioning (e.g., ability to work, shop, cook, pay bills, rerum home without getting lost). Deterioration of language functio n (aphasia) may be manifested by d ifficulty produci ng the n ames of individuals and objects (C riterion A2a). T he speech of individuals w ith aphasia may become vague o r em pty, with long circumlocutory pluases and excessive lise of terms of indefinite refe rence such as " thing" and "it." Comprehension of spoken and written language and repetition of language may also be compromised. In the advanced stages of dementia, individuals may be mute or have a deteriorated
Dementia
149
speech pattern characterized by echolalia (i.e., echoing what is heard) o r palilalia (i.e., repeating sounds or words over and over). Language is tested by asking the individual to name objects in the room (e.g., tie, dress, desk, lamp) or body parts (e.g., nose, chin, shoulder), follow commands ("Poin t at the door and then at the table"), or repeat phrases ("no ifs, ands, or buts"). Individuals with dementia may exhibit apraxia (i.e., impaired ability to execute motor activities despite intact motor abilities, sensory ftmction, and comprehension of the required task) (Criterion A2b). They will be impaired in their ability to pantomime the u seof objects (e.g ., combing hair) or to execute known motor acts (e.g., waving goodbye) . Apraxia may contribute to deficits in cooking, dressing, and drawing . Motor skill d is turbances may be tested by asking the individual to execute motor flUlctions (e.g., to show how to brush teeth, to copy intersecting pentagons, to assemble blocks, or to arrange sticks in specific designs). Individuals with dementia may exhibit agnosia (i.e., failure to recognize or identify objects despite intact sensory function) (Criterion A2c). For example, the individual may have normal visual acuity but lose the ability to recognize objects s uch as chairs or pencils. Eventually they may be unable to recognize family members or e\'en their own reflection in the mirror. Similarly, they may have normal tactile sensation, but be unable to identify objects placed in their hands by touch alone (e.g., a coin or keys). Disturbances in executive functioning are a common manifesta tion of dementia (Criterion A2d) and may be related especially to disorders of the frontal lobe or associated subcortical pathways. Executive flUlctioning involves the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior. Impairment in abstract thinking may be manifes ted by the individual having difficul ty coping with novel tasks and avoiding situations that require the processing of new and complex information. The ability to abstract can be formally assessed by asking the person to find similarities or differences between related words. Executive dysfunction is also evident in a reduced ability to shift mental sets, to generate novel verbal or nonverbal information, and to execute seria l motor acti vities. Tests for execu tive function include asking the indi vidual to count to 10, recite the alphabet, subtract serial 7s, state as many anima ls as possible in 1 minute, or draw a continuous line consisting of alternating m 's and n 's. It is also useful to determine (from the individual and informants) the impact of the disturbances in executive functioning on the individual's daily We (e.g., ability to work, plan activities, budget). The items in both Criterion Al (memory impairment) and Criterion A2 (a phasia, apraxia, agnosia, or disturbance in executive hmctioning) mus t be severe enough to cause significant impairment in social or occupational ftmctioning (e.g ., going to school, working, shopping, dressing, bathing, handling finances, and other activities of daily living) and must represent a decline from a previous level of functioning (Criterion B). The nature and degree of impairment are variable and often depend on the particular social setting of the individual. The same level of cognitive impairmen t may significantly impair an individual's ability to p erfonn a complex job, but not a job that is less demanding. Standardized published rating scales that measure physical maintenance (e.g., personal hygiene), intellectual flUlctionin g, and the ability to use implements o r tools (e.g., telephone, washing machine) can be used to measure the severity of impairment.
150
Dementia is not diagnosed if these symptoms occur exclusively during the course of a delirium. However, a delirium may be superimposed on a preexisting dementia,
in w hich case both diagnoses s hould be given.
Dementia
151
Associated physical examination findings and general medical conditions . The associated physical examination findings of dementia depend on the nature, location, and stage of progression of the wlderlying pathology. The mos t conunon cause of dementia is Alzheimer's disease. Other frequent forms include Vascula r Dementia and dementia due to other nemodegenerative processes, s uch as Lewy bod y disease (including dementia due to Parkinson's disease) and frontotemporal degeneration (including Pick's disease). Other causes are less conunon and include normal-pressme hydrocephalus, H untington's disease, traumatic brain injury, brain tumors, an oxia, infectious disorders (e.g., human immunodeficiency virus [HIVJ, syphilis), prion diseases (e.g ., Creutzfeldt-Jakob d isease), endocrine conditions (e.g., hyp othyroidism, hypercalcemia, hypoglycemia), vitamin deficiencies (e.g ., deficiencies of thiamine or niacin), inunune disorders (e.g., temporal arteritis, systemic lupus e ryUlematosus), hepatic conditions, metabolic conditions (e.g., Kufs' disease, adrenoleukodystrophy, metachromatic leukodystrophy, and other s torage diseases of adulthood and childhood), and other nemological conditions (e.g., multiple sclerosis) .
Prevalence
Reported prevalence of dementia varies among e p idemiological s tudies, depending on the ages of the subjec ts sampled; methods of determining the presence, severity, and type of cognitive impairment; and the regions or countries studied . Community studies es tima ted a I-year pros pective prevalence of almost 3.0% with severe cogni-
De lirium. Dementia. and Amnestic a nd Other Cognitive Disorders tive impainnent in the adult population. The study assessed individuals with a brief instrument tha t assessed current cognitive status (the Mini-Mental State Exam), which does nol identify specific diagnoses. A variety of epidcmiologicaJstudies have shown Iha tthe prevalence of dementia, especially Dementia of the Alzheimer's Type, increases with age. The p revalence figures range from 1.4% to 1.6% for indiv idua ls ages 65-69 years, rising to 16% to 25% for those over age 85 years.
Course
Historically, the tenn demelltin implied a progressive or irreversible course. The OSMIV d efinition of demelltin, howe\'er, is based on the pa ttern of cognitive deficits and carries no connolation concerning prognosis. Dementia may be progressive, static, or remitting. The reversibility of a dementia is a functjon of the underlying pathology and of the availabili ty and timely applica tion of effective treatment. The mode of onset and subsequent cou rse of dementia also depend on the underlying etiology. The level of disability depends not on ly on the severity of the individual's cognitive impairments but also on the available social supports. In advanced dementia, the individual may become totally oblivious to his or her surroundings and require constant care. Individuals with severe dementia are susceptible to accidents and infectious diseases, which often prove fatal.
Deme ntia
153 1
(acute, subacute, or chronic) may be useful in suggesting the etiology. For example, the severity of the impairment in cognitive functioning often remains static after head injury, encephali tis, or stroke. Multiple cognitive d eficits that occur only in the context of substance use are d iagnosed as Su bstance Intoxicati on or Substance Withdrawal. If the dementia results from the persisting effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure), then Substan ce-Induced Pers isting Dementia is diagnosed. Other causes of dementia (e.g., Dementia Due to a General Medical Condition) should always be considered, even in a person with Substance Dependence. For example, head injury is not infreq uent during substance use and may underlie the d ementia. Although researchers are seeking to develop sensitive and specific tests to confirm the diagnosis of Demen tia of the Alzh eimer's Type, it currently remains a diagnosis of exclusion, and other causes for the cognitive de ficit s (see above) must fi rst be ruled out. In addition, the course is d laracterized by gradual onset and continuing cognitive decline. In those cases in which there is insufficient evidence to determine whether the dementia is due to a general medical condition or is substance induced, De mentia Not Othenvise Specified should be coded. lndividuals may present with some but not all of the symptoms of dementia. Such presentations should be coded as Cogn itive Disorder Not Oth en vise Specified. Mental Retardation is characterized by significantly subaverage current general intellectual functioning, with concurrent impairments in adaptive fun ctioning and with an onset before age 18 years. ~'Ienta l Retardation is not necessarily associated with memory impairment. In contrast, the age at onset of dementia is usually late in life. If the onset of the dementia is befo re age 18 years, both dementia and Menta l Retardation may be d iagnosed if the criteria for both disorders are met. Documenting a significant deterioration in memory and in other cognitive skills, which is necessary for the diagnosis of dementia, may be difficult in persons under age 4 yea rs. In individuals under age 18 years, the diagnosis of dementia should be mad e only if the conclition is not characterized satisfacto rily by the diagnosis of Mental Retardation alone. Schizophrenia can also be associa ted with multiple cognitive impairments and a decline in fun ctioning, but Schizophrenia is unlike dementia in its generally eartier age at onset, its characteristic symptom pattern, and the absence of a specific etiological general medical condition or substance. Typically, the cognitive impairment associated with Schizophrenia is less severe than that seen in Dementia. Ma jor Depressive Disorde r may be associated with complaints o f memory impainnent, difficulty thinking and concentrating, and an overa U reduction in intellectual abilities. Individuals sometimes perform poorly on mental status examinations and neuropsychological testing. Particularly in elderly persons, it is o ften difficult to determine whether cogni tive symptoms are better accounted for by a d ementia or by a Major Depressive Episode. This differential diagnosis may be informed by a thorough medical eval uation and an eva luation of the onset of the disrurbance, the temporal sequencing of depressive and cognitive symptoms, the course of illness, famil y history, and treatmen t response. TIle p remorbid state of the indiv idual may help to differentiate "pseudodementia" (j .e., cognitive impairments due to the Major Depressive Episode) from dementia. In dementia , there is usually a premorbid hi story of decl ining cognitive function, whereas the individual with a Major Depressive Episode is much more likely to have a relatively nonnal premorbid state and abrupt cognitive
154
decline associa ted with the depression. lf the clinician determines that both a dementia and Major Depressive Disorder are present w ith independent etiologies, both should be diagnosed. Dementia must be disting uished from Malingering and Factitious Disorder. The patterns of cognitive deficits presented in Malingering and Factitiolls Disorder are usually not consistent over time and are not characteristic of those typica lly seen in dementia. For example, individuals wi th Factitious Disorder or Malingering man ifes ting as dementia may perfonn calculations w h ile keeping score during a card game, but then claim to be unable to p erform similar calculations during a mental status examination. Dementia must be distinguis hed from the normal decline in cognitive functioning that occurs w ith aging (as in Age-Rela ted Cognitive Decline) . The diagnosis of dementia is warranted only if there is demonstrable evidence of greater memory and other cognitive impairment than would be expected d u e to normal aging processes and the symptoms cause impairment in socia l or occupational flUlctioning.
294.1x'
Diagnostic Features
The cognitive deficits (Cri terion A) and the required impairment (Criterion B) are discussed on pp. 147-150. The o nset of Dementia of the Alzheimer 's Type is gradual a nd involves continuing cogniti ve decline (Criterion C). Because of the d ifficulty of obtaining direct pathological evidence of the presence of Alzheimer's d isease, the diagnosis can be m a de on ly when other etiologies for the demen tia have been ruled out. Specifically, the cognitive deficits are not due to other central ne rvous system conditions that cause progressive deficits in memory or cognition (e.g., cerebrovascular d isease, Parkinson's disease, H lmtington's disease), systemic conditions that are known to cause dementia (e.g ., hypothyroidism, vitamin B12 deficiency, HIV in fection), or the persisting effects of a su bstance (e.g., alcohol) (Criterion D). If there is an a dditional etiology (e.g ., hea d trauma worsening a Dementia of the Alzheimer's Type), both types of dementia should be coded (see Dementia Due to Multiple Etiologies, p. 170). Dementia of the A lzheimer's Type should not be d iagnosed if the symptoms occur exclusively during delirium (Criterion E). However, delirium may be superimposed on a preexisting Dementia of the A lzheime r's Type, i.n which case the With Delirium subty pe should be indica ted . Finally, the cognitive deficits are not better accounted fo r by another Axis I disorder (e.g., Major Depressive Disorder or Schizophrenia) (C riterion F).
Subtypes
The age a t onset of Dem entia of the Alzheimer's Ty pe is indicated by the use of one of the follOWing subtypes:
294 .1x*
155
With Early Onset. This subtype is used if the onset of the dementia is age 65 years or under. Wi th Late Onset. This subty p e is used if the onset of the dementia is after age 65 years. The p resence or absence of a clinically significant behavioral dis turbance is indicated by using one o f the follow ing coded s ubtypes: .10 Without Behavioral Disturbance. This subtype is used if the cognitive disturbance is not accompanied by any clinically significant behavioral dis turbance . .11 With Behavioral Disturbance. This s ubtyp e is used if the cognitive disturbance is accom panied by a clinicall y significa nt beha vioral disturbance (e.g., wandering, ag itation).
Recording Procedures
The diagnostic code depends entirely on the presence or absence of a clinically significant beha vioral dis turbance and not w hether the dementia is of early vers us late onset. Thus, the diagnostic cod e is 294.10 for Dem entia of the Alzheimer's Typ e, With Ea rly O nset, Wi thout Behaviora l Distu rbance; 294.10 for Dementia o f the Alzheimer' s Typ e, With Late Onset, Without Behavioral Dis turbance; . Behavioral Dis turbance. In addition, 331.0 Alzheimer's disease should be coded on Axis III. Other p rominent clinical features related to the Alzh eimer's disease can be indicated by coding the specific additional mental disord ers due to Alzheimer's d isease on Axis I. For example, to indicate the p resence of prominent delusions, clinically siglillicant dep ressed m ood, and the d evelopment of p ersis tent aggressive beha v i o ~1 293.81 Psychotic Disorder Due to Alzheimer's Disease, With Delusions; 293.83 Mood Dis-order Due to Alzheimer's Disease, W ith Depressive Features; and 310.1 Personality Change Due to Alzheimer's Disease, Aggressive Ty pe, w ould also be coded on Axis 1.
156
cerebral ventricles than computed tomog raphy or resonance imaging (1\'00). Microscopic examination u sually reveals histopathological
changes, including senile plaques, neurofibrillary tangles, granulovascular degenera tion, neu ronal loss, astrocy tic gliosis, and amyloid angiopa thy . Lew)' bodies are
Prevalence
TIle p revalence of Dementia o f the Alzheimer's Type increases dramatically with increasing age, rising from 0.6% in males and O.S"/o in females at age 65 (all levels of severity) to 11% in males and 14% in females at age 85. At age 90 the p revalence rises to 21% in males and 25% in females, and by age 95 the p revalence is 36% in ma les and 41 % in females. Moderate to severe cases make up about 40%-60% of these estimated prevalence rates.
Course
See p. 152 for a genera l d iscussion of the course of dementia. The course of Dementia of the Alzheimer's Type tends to be slowly progressive, with a loss of 3-4 points per year on a standard assessment instrument such as the Mini-Mental State Exam . Various patterns of deficits are seen. A common pattern is an insidious onset, with early deficits in recent memory foll owed by the development of aphasia, apraxia, and agnosia after several years. Many individuals show personality changes, increased irritability, and other behavioral signs and symptoms, starting in the early stages and becoming most pronounced in the middle stages of the disease. In the later stages of the disease, individuals may d evelop gai t and motor disturbances and eventually become mute and bedridden. The average duration of the illness from onset of symptoms to death is 8-10 years.
Famili al Pattern
Compared with the genera l popu lation, firs t-degree biological relatives of individuals with Dementia of the Alzheimer's Type, With Early Onset, are more likely to develop the disorder. Late-onset cases may also have a genetic component. Dementia of
294 .1 x*
157
the Alzheimer's Type in some families has been shown to be inherited as an au tosomal dominant trait with linkage to severa l chromosomes, including chromosomes 1, 14, and 21 . However, the proportion of cases that are related to specific inherited abnonnalities is not known . Individuals carrying one or both alleles cod ing for apolipoprotein E-4 (APOE4) on chromosome 19 bear an eleva ted risk for later-onset Alzheimer' s di sease, although this gene is not itself a cause of the disorder.
Differential Diagnosis
See p . 152 for a general discussion of the differential diagnosis of dementia.
v(, )
memory impairment (impaired ability to learn new information or to recall previously learned information) (2) one (or more) of the following cognitive disturbances: via) aphasia (language disturbance) (b) apraxia (impaired abi lity t o carry out motor activities despite intact motor function) (c) agnosia (fa ilure to recognize or identify objects despite intact sensory function) (d) disturbance in execut ive functioning (i.e., planning, organizing, seq uencing, abstracting)
B. / The cognitive deficits in Criteria Al and A2 each cause significant impairment in soJ cia I or occupational functioning and represent a significant decl in e from a previous level of functioning.
..-c.
The course is character ized by gradual onset and continuing cognitive decline .
D. The cognitive deficits in Criteria A l and A2 are not due t o any of the following:
~ other
,y
central nervous system condi t ions that cause progressive deficits in memory and cognition (e .g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hemat oma, normal-pressure hydrocephalus, brain tumor) (2) systemic conditions that are known to cause dementia (e.g ., hypothyroidism, ...../" vi tamin B I I or folic acid deficiency, n iacin deficiency, hypercalcemia, neurosyphi lis, HIV infection) (3) substance-in duced conditions
1,./
/ 'The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia).
Code based o n presence or absence of a clinically sign ificant behavioral disturbance:
294.10 Without Behavioral Disturbance: if the cog nitive disturbance is not accompanied by any clinically sign ificant behavio ral disturbance.
158
With Early Onset: if onset is at age 65 years or below With Late Onset: if onset is after age 65 years
Coding note: Also (ode 33 1.0 Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer's disease on Axis I (e.g ., 293 .83 Mood Disorder Due to Alzheimer's Disease, With Depressive Featu res, and 310.1 Personal ity Change Due
Subtypes
By ICD-9-CM convention, Vascular Dementia is the only type of dementia that employs subtypes to indicate the presence of significant associated symptoms. The following subtypes (each of which has its own separa te code) must be used to indicate the predominant featu re of the cu rrent clinical presentation: With Delirium. This subtype is used if delirium is superimposed on the dementia. With Delusions. This subtype is u sed if delusions are the predominant feature.
290Ax
159
With Depressed Mood. This subtype is u sed if depressed mood (including presentations that meet symptom criteria for a Major Depressive Episode) is the predominant feahue. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given . Uncomplicated. This s ubtype is used if none of the above predominates in the CLUrent clinical presentation. The specifier With Behavioral Disturbance (whicll CiUUlot be coded) C1n also be . used to indicate clinically significant behavioral disturbances (e.g., wandering).
Recording Procedures
By ICD-9-CM convention, only Vascular Dementia has cod able subtypes. The diagnostic codes for Vascwar Dementia depend on the subtype for predominant features: 290.41 for \OVith Delirium, 290.42 for With Delusions, 290.43 for With Depressed ~'Iood, 290.40 for Uncomplicated . The specifier \o\'ith Behavioral Disturbance is uncoded and can be applied to each of the above subtypes (e.g., 290.43 Vascular Dementia, With Depressed Mood, With Behavioral Disturbance). In addition, the cerebrovascular condition (e.g., 436 stTOke) should be coded on Axis lil.
160
Preva lence
Vascul ar Demen tia is reported ly much less common than Dementia of the Alzhei-
mer's Type.
Course
See p. 152 for a general discussion of the course of dementia. The onset of Vascular Demen tia is typicaUy abrupt. followed by a stepwise and fl ucruating course th at is characterized by rapid changes in fu nctioning rather than
slow p rogression. The course, however, may be highly variable, and an insidious onset with gradual decline is also encountered. Usually the pattern o f defi cits is "pa tchy," depending on w hich regions of the brain h ave been d estroyed. Certain cognitive functions may be affected early, whereas o thers remain relatively unimpaired. Early treatment of hypertension and vascu lar d isease may prevent fu rther progression.
Differential Diagnosis
See p. 152 for a genera l d iscussion of the differential d iagnosis o f dementia.
290.4x
161
viously learned information) (2) one (or more) of the fol lowing cognit ive disturbances: (a) aphasia (language disturb ance) (b) apraxia (impaired ability to ca rry out motor activit ies despite intact motor function) (c) agnosia (failure to recognize or identify objects despite intact sensory function) (d) disturbance in execut ive f unction ing (i .e., planning, organizing, sequencing, abstracting) B. The cogni t ive deficits in Criteria Aland A2 each cause signi fi cant impairment in social or occupational functioning and represent a sign ificant decline from a previous level of functioning.
C. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extrem ity) or laboratory evidence ind icative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance. D. The deficits do not occur exclusively during the course of a delirium.
Code based on predominant features:
290.41 With Delirium: if del iriu m is superimposed on the dementia 290.42 With Delusions: if de lusions are the predominant feature 290.43 With Depressed Mood: if depressed mood (including presentations tha t meet full symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condit ion is not given. 290.40 Uncomplicated: if none of the above predominates in t he current cl in ical presentation
Specify if:
With Behavioral Disturbance Coding note: Also code cerebrovascu lar condit ion on Axis III.
Subtypes
The p resence or absence of a clinica lly Significant behavioral d is turbance can be indio cated by using on e of the fo llowing coded subtyp es: .10 With ou t Behavioral Disturbance. This s ubtype is used if the cognitive d isturbance is not accompanied by any clinica lly significant behavioral disturbance . .11 With Behavioral Disturbance. This subtype is used if the cognilivedisturbance is accompanied by a clinically significant behavioral d isturbance (e.g., wandering, agitation).
294.1x
Re co rding Procedures
The diagnostic codes are selected depending on whether there is a clinically significant behavioral di sturbance (i.e., the d iagnostic code 294.10 appl ies when there is no clinica lly Significant behavioral disturbancc, and 294.11 applies when there is a clinically significant behav ioral di stu rba nce accompanying the cogniti ve defi cits). The ICD-9-CM code for the etiologica l condition should also be noted on Axis HI (e.g., 332.0 Pa rkinson's disease, 331.1 Pick's d isease, 244.9 hypothyroidism). (See Appendix G for a list of selected ICD-9-CM diagnostic codes for general medical conditions.) In an ind ividual with an established history o f a dementia, a superimposed Delirium Due to a General Medical Condition should be noted by cod ing both the dementia and the delirium on Axis I (e.g., 294.1 Dementia Due to Parkinson's Disease and 293.0 Delirium Due to Hepatic Encephalopathy). This is in contra st to Vascular Dementia, in w hich the 'Vith Delirium subtype is specified. Other prominent dinical features related to the etiological general medica l condition can be indicated by coding the s pecific additional Mental Disorder Due to General Medical Condition on Axis J. For example, to indica te the presence of prominent delusions, c1inical1y significant depressed mood, and a change to a labile personality in an indiv idual with Dementia Due to Parkinson's Disease, 293.81 Psychotic Disorder Due to Parkinson's Disease, With Delusions; 293.83 Mood Disorder Due to Parkinson's Disease, With Depressive Features; and 310.1 Personality Change Due to Parkinson's Disease, Labile Type would also be coded on Axis I.
294.1x
The essential fea ture of Dem entia Due to HIV Disease is the p resence of a dementia that is judged to be the direct pathophysiological consequence of human immunodeficiency virus (HI\') disease. Neuropathological findings most commonly involve diffuse, multifocal destruction of the white matter and subcortical structures. The spinal nuid may show normal or slightly elevated protein and a mild lymphocytosis, and H1V can usually be isolated directly from cerebrospinal nuid. Dementia that is associated with direct HIV infection of the central nervous system is typically characterized by forgetfulness, slowness, poor concentration, and difficulties with problem solving. Behavioral manifestations most commonly includfLa Pjtili and social withdrawal, an occaSionally these may' be accompanied by-delirium, dclusions, or hal!\lcina tio@j. Tremor, impaired rapid repetitive movements, imba lance, ataxia, hypertonia, generalized hyperrenexia, positive frontal release signs, and impaired pursuit and saccadic eye movements may be present on physical examination. Children may also develop Dementia Due to HIV Disease, typically manifested by developmental delay, hypertonia, microcephaly, and basal ganglia calcifica tion. Dementia in association with HIV infection may also result from accompanying central nervou s system tumors (e.g., primary central nervous system lymphoma) and from opportunistic infections (e.g ., toxoplasm osis, cytomegalovirus in fection, cryptococcosis, tuberculosis, and syphilis), in which case the appropriate ty pe of d ementia should be diagnosed (e.g., 294.1 Dementia Due to Toxoplasmosis). Unusua l systemic infections
' ICD-9-C1\! code \'alid after October 1, 2000.
164
(e.g., Pllel/maryslis cnrillii pneumonia) or neoplasms (e.g., Kaposi's sarcoma) may also be present.
294.1x*
The essential feature of Dementia Due to Head Trauma is the presence of a dementia that is judged to be the direct pathophysiological consequence of head trauma. The degree and type of cognitive impairments o r behavioral disturbances d epend on the loca tion and extent of the brain injury. Posttraumatic amnesia is frequently present, along with peTSisting memory impairment. A variety of other behaviora l symptoms may be evident, with or w ithout the presence of motor or sensory defici ts. These symptoms include aphasia, attentional problems, irritability, anxiety. depression or affective lability. apathy. increased aggression. o r other changes in personality. Alcohol or other Substance Intoxication is often p resent in individuals with acute head injuries, and concurrent Substance Abuse or Dependence may be present. Head injury occurs most often in young males and has been associated with risk-taking behaviors. When it occurs in the context of a single injury, Demen tia Due to Head Trauma is u sually nonprogressive, bu t repeated head injury (e.g., from boxing) may lead to a progressive dementia (so-called dementia pugilistica). A single h ead trauma that is followed by a p rogressive decline in cognitive function should raise the possibility of another superinlposed process sllch as hydrocephalus or a Major Depressive Episode.
294.1x*
The essential feature of Dementia Due to Parkinson's Disease is the presence of a dementia that is judged to be the direct pathophysiologica l consequence of Pa rkinson's disease. Parkinson's disease is a slowly progressive neurological condition, characterized by tremor, rigidity, bradykinesia, and postural instability. Dementia has been reported to occur in approximately 200/0-60% of individuals with Parkinson's d isease and is more likely to be presen t in older individuals or those with more severe or advanced disease. The dementia associated with Parkinson's disease is characterized by cognitive and motoric slowing, executive d ysfunction , and impairment in memory rehieval Declining cognitive performance in individual s with Parkinson's disease is frequently exacerbated by depression. Findings on physical examination include the characteristic abnormal molor signs of resting tremor, evidence of slowness and poverty of movement (such as micrographia), or muscular rigidity and loss o f associated movements. At autopsy, neuronal loss and Lewy bodies are evident in the substantia nigra. There are a number of syndromes that may manifest with dementia, parkinsonian movement disorders, and additional neurological features (e.g., progressive supranuclear palsy, oiivopontocerebellar d egeneration, and Vascular Dementia). Some individuals w ith Parkinson's disease and dementia are found at autopsy to have coexisting neuropa thology indicative of Alzheimer's disease or of diffuse Le\\'y body disease. Dementia due to Lew}' Body Disease in the absence of evidence of Parkinson's (such as tremor and cogw heel rigidity) should be diagnosed as Dementia
"ICO-9-CM code valid after October 1, 2000.
294.1x*
Due to Lewy body disease, one of the dementias due to other general medical conditions (see p. 167).
294.1x*
The essential feature of Dementia Due to Huntington's Disease is the presence o f a dementia that is judged to be the direct pathophysiological consequence of Huntington's disease. Huntington 's disease is an inherited progressive degenerative disease of cognition, emotion, and movement. The disease affects men and women equally and is transmitted by a single autosomal dominant gene on the short ann of chromosome 4. The disease is usually diagnosed in the late 30s to early 40s bu t may begin as early as age 4 years in the juvenile form or as late as age 85 years in the late-onset fom,. The onset of HWltington's disease is often heralded by insidious changes in behavior and personality, including depression, irritability, and anxiety. Some individuals present with abnomlalities of movement that resemble increased fidge ting and that later progress to characteristic generali zed choreoathetosis. Difficu lties w ith memory retrieval, executive functioning, and judgment are common early in the (mu se, with more severe memory deficits occurring as the disease progresses. Disorganized speech and psychotic feahue s are sometimes present. Late in the disease, characteristic "boxcar ventricles" may be seen on structural brain imaging due to the atrophy of the striatum. Positron-emission tomography (PET) may show striatal hypometabolism early in the disease. Offspring of individuals with Huntington's disease have a 50% chance of developing the disease. A genetic test is available to determine with relative certainty whether a given at-risk individual is likely to develop the disease; however, such testing may be best administered by cen ters with experience in counseling and foUow-up of individuals at risk for Huntington's disease.
294.1x*
The essential feature of Dementia Due 10 Pick's Disease is the presence of a dementia that is judged to be the direct pathophysiological consequence of Pick's disease. Pick's disease is a d egenerative disease of the brain that particularly affects the fronta I and lemporallobes. As in other frontal lobe dementias, Pick's disease is characterized clinically by changes in personality early in the course, deteriora tion of social skills, emotional blunting, behavioral disinhibition, and prominent language abnormaJities. Difficulties with memory, apraxia, and other features of dementia usuaUy foUow later in the course. Prominent primitive reflexes (snout, suck, grasp) may be present. As the dementia progresses, it may be accompanied by either apathy or extreme agitation. Individuals may develop such severe problems in language, attention, or behavior that it may be difficult to assess their degree of cognitive impairment. Structural brain imaging typica lly reveals prominent fron tal and / or temporal atrophy. and functional brain imaging may loca lize fron totemporal hypometabolism, even in the absence of clear structural atrophy. The disorder m ost commonly manifests itself in individuals between ages 50 and 60 years, although it can occur among older individuals. Pick's disease is one of the path ologically distinct etiologies among the heterogeneous group of dementing processes that are associated with frontotemporal brain
'ICD-9-C~'1
166
atrophy. The specific diagnosis of a frontal lobe dementia s uch as Pick's disease is usually es tablished a t autop sy with the pathological finding of ch aracteristic intraneuronal argentophilic Pick inclusion bodies. C linically, Pick's d isease often (anno!
be distinguished with certainty from atypical cases of Alzheimer's disease or from other dementias that affect the frontal1ohes. Dementia due to frontotemporal degenera tion other than Pick's d isease s hould be diagnosed as Dementia Due 10 Frontotemporal Degeneration, one of the dementias due to o th er general medical conditions (see p. 167).
294.1 x*
167
Differential Diagnosis
See p. 152 for a general di scussion of the d ifferential diagnosiS o f demen tia .
1168
Diagnostic criteria for 294.1x Dementia Due to Other General Medical Conditions
A. The development of multiple cognitive d eficits manifested by both
(1 ) memory impairment (impa ired ability to learn new information or to recall previously learned information) (2) one (or more) of the following cognitive disturbances:
(al aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities despite intact motor
function)
ing, abstracting)
B. The cognitive deficits in Criteria A l and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C. There is evidence from the history. physical examination, or laboratory find ings that the disturbance is the direct physiological consequence of a general medical conditi on other than Alzheimer's disease or cerebrovascular disease (e.g., HIV infection. traumatic brain injury, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease, normal-pressure hydrocephalus. hypothyroidism, brain t umor, or vitamin 8 12 deficiency).
D. The deficits do not occur exclusively during the course of a delirium.
Code based on presence or absence of a clinically significant behavioral disturbance:
if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance. 294 ,11 With Behavioral Disturbance : if the cognitive disturbance is accompan ied by a clinically significant behavioral disturbance (e.g., wanderi ng. agitation). Coding note: Also code the general medical condition on Axis 111 (e .g., 042 H1V infection. 854 .00 head injury, 332 .0 Parkinson's disease, 333.4 Huntington's disease. 331.1 Pick's disease, 046.1 Creutzfeldt-Jakob disease; see Appendix G for additional codes).
169
must be evidence from the history, physical examination, or laboratory finding s that the deficits are etiologically related to the persisting effects of substance lise (e.g., a drug of abuse, a medication, toxin exposure) (Criterion D). This disorder is termed "persisting" because the d ementia persists long after the individual has experienced the effects of Substance Intoxication or Substance Withdrawal. Features that are associated with Substance-Induced Persisting Dementia are those associated with dementias generally (see p. 147). E\'en if currently abstinent from substance U5e, most individuals wi th this disorder have previously had a pattern of prolonged and heavy substance use that met criteria for Substance Dependence. Because these disorders persist long after use of the substance has stopped, blood or urine screens may be negative for the etiological substance. The age at onset of Substance-Indu ced Persisting Dementia is rarely before age 20 years. This disorder usually has an insidious onset and slow progression, typically during a period when the person qualifies fo r a Substance Dependence diagnosis. The deficits are usually permanent and may worsen even if the substance use stops, although some c.lses do show improvement. For a more detailed discussion of the features associated with Substance-Rela ted. Disorders, see p. 191 .
Recording Procedures
The name of the diagnosis begins with the specific substance (e.g., alcohol) tha t is presumed to have caused the dementia. The diagnostic code is selected from the listing of classes of substances provided in the cri teria set. For substances that do not fit into any of the classes, the code fo r "Other Substance" should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code (see Appendix G). When more than one subst.lOce is judged to playa significant role in the development of the persisting dementia, each should be listed separately (e.g., 291.2 Alcohol-Induced Persisting Dementia; 292.82lnhalant-lnduced Persisting Dementia). If a substance is judged 10 be the etiological fa ctor, but the specific substance or class of substances is unknown, Ihe diagnosis is 292.82 Unknown Substance-Induced Persisting Dementia.
Differential Diagnosis
See p. 152 for a genera l discussion of the differential diagnosiS of dementia .
170
vious ly learned information) (2) one (or more) of the following cognitive di stur bances:
(a) aphasia (language distu rbance) (b) apraxia (impaired ability to carry out motor activities despite intact motor function)
(e) a gnosia (failure to recognize o r ide ntify objects despite intact sensory
function) (d) disturbance in executive functioning (i .e., planning, organizin g, sequenc-
ing, abstracting)
B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in so cial or occupational functioning and represent a significant decl ine from a previous level of functioning .
C
The deficits do not occur exclusively during the course of a deli rium and persist be yond t he usual duration of Substance Intoxication or Wit hdrawal.
D. There is evidence from the history, physical exam inat ion, or laboratory findi ngs that the deficits are etiologically related to the persisting effects of substance use (e.g., a drug of abuse, a medication) .
Code (Specific SubstanceHnduced PerSisting Dementia :
(29 1.2 Alcohol; 292.82 Inhalant; 292.82 Sedative. Hypnot ic. or Anxiolytic; 292 .82 Other (or Unknownl Substance)
294.8
171
course of severa l strokes, develops a significant further decline in cognitive functioning. In this example, the clinician wou ld lis t both 294.10 Dementia of the Alzheimer's Type, With Late Onset, Without Be haviora l Disturbance, and 290.40, Vascular Dementia, Un complicated, on Axis I, and 331.0 Alzheimer's Disease and 436 Stroke on Axis rn.
viously learned information) (2) one (or more) of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities despite intact motor functi on) (c) agnosia (failure to recognize or identify o bjects despite intact sensory function) (d) disturbance in executive function ing (i.e., plann ing, organizing. sequencing, a bstracting)
8. The cognitive deficits in Criteria Aland A2 each cause significant impairment in so-
cial or occupationa l functioning and represent a significant decline from a previous level of functioning.
C. The re is evidence from the history, physica l examination, or laborato ry findings t hat
the disturbance has more than one etiology (e.g., head trauma plus chronic alcohol use, De mentia of the Alzheimer'S Type with the subsequent development of Vascular Dementia).
D. The deficits do not occur exclusively during the course of a delirium.
Coding note: Use multiple codes based on specific dementias and specific etiologies, e.g., 294.10 Dementia of the Alzheimer's Type, With l ate Onset, Without Behavioral Disturbance; 290.40 Vascula r Dementia. Uncomplicated .
294.8
an)'
This catego ry should be used to d iagnose a dementia tha t does not meet criteria for
of the specific types described in this sec-lio n. An example is a clinical presen tation o f dementia for which there is ins ufficient evidence to establis h a speci fi c etiology.
The disorders in the " Amnestic Disorders" section are characterized by a disturbance in memory tha t is either due to the direct physiological effects of a general medical condition or due to the persisting effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure). The disord ers in this section sh are the common symptom presentation of memory impairment, but are differentiated based on etiology. The ctiagnostic features listed below pertain to Amnestic Disorde r Due to a General Medical Con dition (e.g., physical trauma and vitamin deficiency) and Su bstance-Induced Persisting Amnesti c Disorder (including medication side effects). In addition, Amn estic Disorder Not O thenvise Specified is included in this section for presentations in w hich the clinician is unable to determine a sp ecific etiology for the memory disturbance. Text and criteria for Dissocia tive Disorders involving memory loss are not included here and instead are contained in the Di ssociative Disorders section (see
p.519).
Diagnost ic Features
Indiv iduals with an amnestic disorder are impaired in their ab ility to learn new information or are unable to recall previously learned information or past events (Criterion A). The memory disturbance must be sufficiently severe to cau se marked impairmen t in social or occupational functioning and must represent a significant decline from a previous level of functioning (Criterion B). The memory disturbance must not occur exclusively during the course of a delirium or a dementia (Criterion C). The ability to learn and recall new information is always a ffected in an amnestic disorder, whereas problems remembering previously learned information occur more variably, depending on the location and severity of brain damage. The m emory deficit is most apparent on tasks that require spontaneou s recall and may also be evident when the examiner provides stimuli for the person to recall at a later time. Depending on the specific area of the brain affected, deficits may be p redominantly related to verbal or visual stimuli. In some forms of an amnesti c disorder, the individual rna)' remember things from the very remote past better than more recent events (e.g., a person rna)' remember in vivid detai l a hospital stay that took place a decade before the examination, but may have no idea that he or she is currently in the hospital). The diagnosis is not made if the memory impairment occurs exclusively during the course of a delirium (Le., occurs only in the context of reduced ability to maintain and shift attention). The ability to immediately repeat a sequential string of information (e.g., d igit span) is typically not impaired in an amnestic d isorder. When such impairment is evident, it suggests the presence of an atlentiona l disturbance that may be indicative o f a delirium. The d iagnosis is also not made in the presence of other cognitive defici ts (e.g., apha sia, apraxia, agnosia, di sturbance in executive hmction ing) that are characteristic of a dementia. Individuals with an amnestic disorder rna)' experience major impairment in their social and vocational fun ctioning as a result of their memory d eficits, w hich, a t its extreme, may necessitate supervised living situations to ensure appropriate feeding and care.
Amnestic Disorders
173
Course
Age a t onset and subsequent course of amnestic disorders may be quite variable, d epend ing on the primary pathological process causing the amnestic disorder. Trauma tic brain injury, stroke or other cerebrovascular events, or specific types of neurotox ic exposure (e.g ., carbon m onoxide poisoning) may lead to an acute onset of an amnestic disorder. Other conditions such as prolonged subs tance abuse, chronic neurotoxic exposure, or sustained nutri tional deficiency may lead to an insidious onset. Transient amnesia due to a cerebrovascular etiology may be recurrent, with episodes lasting from several hours to several days. Amnestic Disorders Due to Head Trauma may last for variable amounts of time, with a characteristic pattern of greatest deficit immediately after injury and improvement during the ensuing 2 years (further improvement beyond 24 months has been noted, but less commonly). Disorders due
174
to destruction of middle-temporal lobe s tructures (e.g., from infarction, surgical ablation, or malnutrition occurring in the context of Alcohol Dependence) may cause persisting impa irments.
Differential Diagnosis
Memory impairment is also a feature of delirium and dementia. In delirium, memory dyshmction occ urs in association with impaired consciousness, w ith reduced ability to focus, sus tain, or shift attention. In dementia, memory impairment must be accompanied by multiple cognitive d eficits (i.e., a phasia, apraxia, agnosia, or a disturbance in executive fun ctioning) that lead to clinically s ignificant impairment. An amnestic disorder must be distinguished ITom Dissociative Amnesia and amnesia occurring in the context of other Dissociative Disorders (e.g ., Dissociative Identity Disorder). By definition, an amnestic disorder is due to the direct physiological effects of a general medical condition or subs tance u se. Furthermore, amnesia in Dissociative Disorders ty pically does not involve defi cits in learning and recalling new information; rather, individuals present with a circumscribed inability to recall p revious memories, u sually of a traumatic or s tressful nature. For memory dis turbances (e_g., blackouts) that occur only during intoxication with or withdrawal from a drug of abuse, the appropriate Substance Intoxication or Substance Withdrawal should be diagnosed and a separate amnestic disorder d iagnosis is not made. For memory disturbances that are associated with the use of medic.l tiOn. Ad verse Effects of Medication Not Othem'ise Specified (p. 736) may be noted , with the medication indicated by the u se of an E-cod e (see Ap p endix G). The presumed etiology of the amnestic disorder determines the diagnosis (text and criteria fo r each amnestic disorder diagnosis are provided separately later in this section). If it is judged that the memory d isturbance is a consequence of the direct phys iological effects of a general med ical condition (including head trauma), then Amnestic Disorder Due to a General Medical Condition is diagnosed . If the memory disturban ce results from the persisting effects of a substance (i.e., a drug of abuse, a medication, or toxin exposLUe), then Substance-Induced Persisting Amnestic Disorder is diagnosed . ""hen both a s ubs tance (e.g ., alcohol) and a general medical condition (e.g., head trauma) have h ad an etiological role in the d evelopment of the memory dishubance, both diagnoses are given. If it is not possible to establish a sp.... cific etiology (i.e., d issociative, subs tan ce induced , or due to a general medical condition), Amnestic Disorder Not Othenvise Specified is diagnosed. Amnestic disorder mus t be dis ting uished from Malingering and from Factitious Disorder. This difficult dis tinction can be assis ted by systematic m emory testing (whidl often yields inconsistent results in Factitious Disorder or Malingering) and b)' the absence of a general medical condition or subs tance use that is etiologica lly relat ed to the memory impairment. Amnes tic disorder should be dis tinguished from the less efficient memory characteristic of Age-Related Cognitive Decline, w hich is w ithin the expected age-adjusted normative range for the individual.
294.0
175 1
Specifi e rs
The following specifiers may be noted to indica te the duration of the disturbance. T ransient. This specifier is used to indicate durations usuall y from several hours to a few days and for no more than 1 month. When the diagnosis is made w ithin the first month without waiting for recovery, the term "provisional" may be added. "Transient g lobal amnesia" is a specific form of transient amnestic disorder, characterized by a dense, transitory inability to learn new in-
1176
formation and a variable impaired ability to recall events that occurred jusl before, or in the mids t o f, the etiological cerebrovascular problem. Chronic. This sp ecifier is used for dis turbances that last for more than 1 month.
Recording Procedures
In recording the diagnOSiS of Amnestic Disorder Due to a General Medical Condition, the clinician should note the identified general medical condition judged to be caus.ing the dis turbance on Axis I (e.g . 294.0 Amnestic Disorder Due to Stroke). The ICD-9-CM code (or the general medical condition sh ould also be no ted on Axis ill (e.g., 436 stroke). (See Appendix G fo r a list of selected ICO-9-CM d iagnostic codes for general medical conditions.)
Differentia l Diagnosis
See p . 174 for a discussion of the differential diagnosis of a mnestic disorders.
Diagnostic criteria for 294.0 Amnestic Disorder Due to ... [Indicate the General Medical Condition]
A, The development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information.
B. The memory disturbance causes significant impairment in social or occupational functioning and represents a sign ificant decline from a previous level of functioning.
C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia.
D. There is evidence from the history, physical examination, or laboratory f indings that the disturbance is the direct physiological consequence of a general medical condition (including physical trauma).
Specify if:
Transient: if memory impairment lasts for 1 month or less Chronic: if memory impairment lasts for more than 1 month Coding note: Include the name of the general medical condit ion on Axis I, e.g., 294.0 Amnestic Disorder Due to Head Trauma; also code the general medical condition on Axis III (see Appendix G for codes).
178
Delirium, Dementia, and Amnestic and Other Cog nit ive Disord ers
For a more d e tailed discussion of the features associa ted with Substance-Related Disorders, see p. 191.
Specific Substances
Substance-lnduced Persisting Amnestic Disorder ca n occur in association with the foJlowing classes of substances: alcohol; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Alcohol-Induced Persisting Amnestic Disorder is appa.rently due to the vitamin deficiency that is associated with prolonged, hea vy ingestion of alcohol. Neu.rological disturbances such as periphera l neu.ropathy, cerebelJar ataxia, and m yopathy a.re among the associa ted features. Alcohol-Induced Persisting Amnestic Disorder due to thiamine deficiency (Korsakoff's syndrome) often fo llows an acute episode of Wernicke's encephalopathy, a neurological condition manifested by confusion, ataxia, eye-movement abnonnalities (gaze palsies, nystagmus), and other neu.rological signs. Gradually, these manifes tations subsid e, but a major impainnent of memory remains. If Wernicke's encephalopathy is treated early with large d oses of thiamine, Alcohol-Induced Persisting Amnestic Disord er may no t develop. Although age is not a specific etiological fac lor in the condition, individuals w ho d evelop Alcohollnduced Persisting Amnestic Disorder generally have histories of many years of heavy alcohol use and are most often over age 40 years. Although the mode of onset is typically abrupt, some individuals may develop deficits insidiously over many years, d ue to repeated toxic and nutritional insults, prior to the emergence of a fin al, more dramatically impairing episode apparently related to thiamine deficiency. Once established, Alcohol-Induced Persisting Amnestic Disorder usually persis ts indefi nitely, although there may be slight improvement over time and in a minority of the cases the condition can remit. Impairment is usually quite severe, and lifelong custodial care may be necessary. Sedative..., Hypnotic-, or AnxiolyticInduced Persisting Amnestic Disorder can follow prolonged and heavy use of drugs from this class. The course is variable, and , unlike Alcohol-lnduced Persisting Amnestic Disorder, fu ll recovery can occur. Medications reported to cause amnestic di sorders include anti convulsants and intrathecal methotrexate. Toxins reported to evoke symptoms of
179
JrlUlesia include lead , mercury, carbon monoxide, organophosphate insecticides, and industrial solvents.
C. The memory disturbance does not occur exclusively during the course of a delirium
or a dementia and persists beyond the usua l duration of Substance Intoxication or Withdrawal. D. There is evid ence from the history, physical examination, or laboratory findi ngs that the memory disturbance is etiolog ically related to the persisting effects of substance use (e.g . a drug of abuse. a medication).
Code [Specific Substancel- Induced Persisting Amnestic Disord er:
(29 1. 1 Alcohol; 292.83 Sedative, Hypnotic, or Anxiolytic; 292.83 Other l or Unknown ] Substance)
294.8
This category should be used to d iagnose an amnestic disord er that d oes not meet criteria for any of the specific ty pes described in this section. An example is a clinica l presentation of anUlesia for which there is insuffi cient evidence to establish a specifi c etiology (i.e., d issociative, substance induced , or due to a general med ical condition).
294.9
This category is for disorders tha t are characterized by cognitive d ysfunction presumed to be due to the direct ph ysiological effect of a general medical condition that do no t meet criteria for any o f the specific d eliriums, dementias, or amnestic d isorders listed in this section and that are not betler classified as Delirium Not O therwise Spec-
180
Del irium. De mentia, and Am nestic and Oth er Cogn it ive Disorders
ified, Dementia N ot Otherwise Sp ecified, or Amnes tic Disord er Not O thenvise Specified. For cogni tive d ysfun ction d ue to a specific or unknown s ubstance, the specific Substance-Related Disorder T t O them 'ise Specified category should be used. o Examples incl ude 1. Mild neurocogn itive disord er: impairmen t in cognitive functioning as evidenced by neuropsychological testing or q uantifi ed clinical assessment. accompanied by objective evidence of a systemic general med ical condition or cenuit\ ner"OU5 system d ysfunction (see p. 762 for suggested research criteria) 2. Postconcussional diso rder: following a head tra uma, impairment in memory or attention with associated symptoms (see p . 760 for sugges ted research criteria)
Mental Disorder Due to il Genera l Medical Condition is characterized by the presence of mental symptoms that aTe judged to be the direct physiological consequence of a general medical cond ition . The term geJleral medical condition refers to conditions that are coded on Axis ill and that are. lis ted outside the "Mental Disorders" chapter of ICD. (See Appendix G for a condensed lis t of these conditi ons.) As d iscussed in the "Introduction" to this manual, maintaining the distinction between mental disorders and general medical conditions does not imply that there are ftm damenlal differences in their conceptualization, that mental disorders are unrelated to ph ysical or biologica l factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial fac tors or processes. TIle purpose o f distinguishing general medical conditions from m ental disorders is to encourage thoroughness in eva luation and to provide a shorthand term to enhance comnHmication amon g health care providers. However, in clinical practice, it is expected that more specific terminology w ill be used to identify the specific condition involved . In DSM-III-R, the Men tal Disorders Due to a General Medical Condition and the Subs tance-Induced Disorders w ere caUed "organic" d isorders and were listed together in a single section. This differentiation of "organic" men tal disorders as a separate class implied that "nonorganic" or "functional " mental disorders were somehow unrelated to physical or biologica l factors or processes. DSM-IV eliminates the term orgall ic and distinguishes those mental disorders that are d ue to a general medical condition from those that are substan ce induced and those that have no specified eti ology . The term primanj mell fal disorder is used as a shorthand to indicate those mental disorders that are not due to a general medical condition and that are not substance induced. Text and criteria for three of these disorders (i .e., Catatonic Disorder Due to a General Medical Condition, Pe rsonality C hange Due to a General Medical Condition, and Mental Disorder Not Otherwise Specified Due to a Ge neral Medical Condition) are included in this section. The text and criteria for the conditions listed below are placed in other sections of the m anual with disorders with which they share phenomenology. The manual h as been o rga nized in this fashion to alert clinicians to consider these disorders in ma king a differential diagnosis.
Delirium Due to a General Medical Condition Text and criteria are included in the "Deliriu m, Dementia, and Amnestic and O ther Cogniti ve Disorders" section, p. 141.
293.0
181
182
Dementia Due to a General Med ical Condi tion Text and criteria are in- 'eluded in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section, p. 162. 294.0 Amnestic Disorder Due to a General Medical Condi tion Text and criteria are included in the "Delirium, Dementia, and Amnestic a nd Other Cognitive Dis ord ers" section, p. 175. 293.8x Psychoti c Disorder Due to a General Medical Conditi on Text and criteria are included in the "Schi zophrenia and Other Psychotic Disorders" section, p. 334. 293.83 Mood Disorder Due to a Gen eral Medical Cond ition in cluded in the "Mood Disorders" section, p. 401. Text and cr iteria are
293.84 Anxiety Disorder Due to a General Medical Con dition are included in the "An xiety Di so rders" section, p. 476.
-,-_ _ Sexual Dysfun cti on Due to a Gen eral Medical Condition Text and eritf'ria are included in the "Sexual and Gender Identity Disorders" section, p. 558. 780.5x Sleep Disord er Due to a Gen eral Medical Condi tion incl uded in the "Sleep Disorders" section, p. 651 . Text and criteria are
Diagnostic Features
Th ree criteria appear in the criteria sets fo r each of the Mental Disorders Due to a General Medical Condition: B. There is evidence from the history, physi cal examin ation, or laboratory findings that the d isturban ce is the direct physiological conseq u ence of a general medical cond ition . Application of this criterion requires h vo separate judgments: that a general medical condition is present (ascertained by history, physical examination, or laboratol)' assessment) and that the disturbance (e.g., psycho tic, mood , anxiety symptoms) is etiologica lly related to the general medical condition through a physiological mechanism. It should be recognized that whether or not a d isturbance is or is 110 t due to the d irect physiological effects o f a general medical cond ition often rep resen ts a false di cho tomy- that is, a gen eral med ical condition may be p art of but n ot the sole etiology of the d isturbance. [n any case, although there are no infallible g uidelines for deter mining w hether the relationship betw een the general medica l condition and the dis turbance is etiological, severa l considerations provide gu idance in this area. One consideration is the presence o f a temporal association between the onset, exacerba tion, or remission of the general medical condition an d that of the mental di sorder (e.g., sym p toms of anxiety in an individual with a pa rathy roid adenoma tha t resoh'e after surgical excision restores a normal serum calciu m level). Although evidence of a close temporal relation sh ip is often u sefu l in making a judgment about etiology,
183
there are many exceptions. For example, Psychotic Disorder Due to Epilepsy can emerge many years after the onset of seizures. Alternatively, symptoms and signs of a menta l disorder can be among the first manifestations of a systemic or cerebral disease, appearing months or more before the detection of the underlying pathological process (e.g., depressed mood preceding choreiform movements in Huntington's disease). Men tal Disorders Due to a General Medica l Condition can also persist after the general medical condition has resolved (e.g., depressed mood persisting after thyroid hormone replacement). Moreover, a Mental Di sorder Due to a Generallvledical Condition can be amenable to symptomatic treatmen t even while the general medical condition remains acti ve (e.g., depression in epilepsy). Treatment targeted to the general medical condition that alleviates the symptoms of both the general medical condition and the mental disturbance may provide stronger evidence of an etiological relationship. A second important consideration is the presence of features that are atypica l of the primary mental disorder. The most common example is an atypical age at onset or course (e.g., first appearance of schizophrenic-like symptoms in a 75-year-old individual). There may be unusual associated features (e.g., visual or tactile halluci nations accompanying major depressive-like episodes) or diagnostk features that are disproportionately more severe than would be expected given the overall presentation (e.g., a 5G-pound weight loss in an individual with othenvise mi ld d epressive symptoms might suggest the presence of a underlying general medical condition). The clinician should be alerted especially by the presence o f Significant cognitive d eficits that are out of proportion to those ty pically encountered with the primary mental disorder. Evidence from the literature of a well-established or frequently encountered association behveen the general medical condition and the phenomenology of a specific mental disorder may be useful in the evaluation of a particular situation. Such stud ies may p rOVide evidence of a plaUSible etiological association between the menta l symptoms and the general medical condition (e.g., lesion location or a known pa thophysiological mechanism likely to affect brain function ) and of an elevated prevalence rate of the mental symptoms (i.e., above the base rate in an appropria te control population) in individuals with the general medical condition. Although such evidence suggests a possible causal link between a mental disorder and a particular gen efal medica l condition, it is not sufficient for making a determination in an individua l case because research studies generally reflect group means, whereas the clinician seeks to make a decision regarding an individual The text for each of the specific Mental Disorders Due to a General Medical Condition contains a list of some of the genefill medical cond itions noted in the literature to be associa ted with that specific menta l disorder.
C. The disturbance is not beller accounted for by another mental diso rder.
In making the diagnosis of a Mental Disorder Due to a General Medical Condition, it is necessary to rule out primilT}' mental disorders and menial disorders that are substance induced . Ruling ou t primary mental disorders is oft en difficult becau se individuals w ith primary mental disorders commonly have co-occurring general medical conditions that are /lot causing the mental symptoms through direct physiological
Mental Disorders Due to a General Medica l Cond it ion mechanisms. There may be a number of other relationships between a mental disor der and a general m ed ical condition: the general medical condition may exacerbate the symptoms or complicate treatment of the mental d isorder; the hvo may be related through non physiological mechanisms; or theca.occurrence may be coinciden tal For example, when de preSSive symptoms are precipitated by the general medical condi tion acting as a psychosoci al stressor, rather than resu lting from the d irect physiolog ical effects of the general medical condition, the diagnosis would be Major Depressive Disorder or Adjustment Disorder With Depressed Mood. In an individual with de pressive symptoms that cooccur with a general medical condition, a history of many Major Depressive Episodes or a family his tory of depression would suggest a diagnosis of Major Depressive Disorder, rather than a Mood Disorder Due to a General Medical Condition. Finally, the clinician should also consider whether the mental symptoms are caused by a drug of abuse, a medication, o r toxin exposure (see p. 209 fo r guidelines). This is especially important because many individuals with general medical conditions receive medications that may have the potential to cause a Substance-Induced Mental Disorder. D. T he dis turbance d oes n ot occur exclus ively du ring the course of a d elirium.
If symptoms (e.g., p sychotic, mood, anxiety) occur only during periods of delirium, they a re considered to be associated features of the delirium and do not warrant a sepa rate diagnosis. These cond itions (e.g., Mood Disorder Due to a General Medical Condition) can be diagnosed separately only if they occur at times other than during the delirium .
Recording Procedures
Ln recording a Mental Disorder Due to a General Medical Condition, the clinician should note both the type of mental disturbance and the etiological general medical condition on Axis I (e.g., 293.83 Mood Disorder Due to H yp othyroidism, With De-pressive Features). The ICD9-CM code for the general medical cond ition (e.g., 244.9 hy pothyroidism ) should also be noted on Axis Ill . In s ituations in which the clinician has determined that the mental symptoms are not a direct phys iological consequence of the general medica l condition, the p rimary mental disorder should be coded on Axis I and the general medica l condition should be coded on Axis lII. (See AppendiX C for a list o f selected ICD-9.(M diagnostic codes for general medical conditions.)
Differential Diagnosis
A Mental Disorder Due to a General Medical Condition is distinguished from a pri mary men tal disord e r by applying the crite ria discussed earlier in th is section under " Diagnostic Features." When symptoms of a mental disorder and a general medical condition co-occur, it is especially importan t to determine whether the etiological relationship, if a ny, is directly phYSiological (in which case the d iagnosis is Mental Disorder Due to a General Medical Condition) or through another mechanism (in which case the diagnosis is a primary mental disorder). In some cases, the development of a general medical condition or the presence of associated disa bility may precipitate or
293.89
185
exacerbate a mental disorder, w ith no known physiological link (e.g., the disability associated with osteoarthritis may playa role in the development of depressive symptoms or a Major Depressive Episode, but there is no know n physiological mechanism underlying the etiological relationship behveen the arthritis and the depressive symptoms). In this situation, the primary mental disorder (i.e., Adjustment Disorder or Major Depressive Disorder) shou ld be diagnosed on Axis I and the general medical condition (i.e., osteoarthritis) shou ld be listed on Axis III. A Mental Disorder Due to a General Medical Condition mus t also be distinguished from a Substance-Induced Disorder. If there is e\'idence of recent or prolonged use of a substance (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a Substance-Induced Disorder should be considered . It m ay be u seful to obtain a urine or blood drug screen or other appropriate laboratory evaluation . Symptoms that occur during or s hortly after (i .e., w ithin 4 weeks of) significant substance in toxica tion or withdrawal or medication use may be especially indicative of a Substance-Induced Disorder, depending on the type or the amount of the substance used o r the duration o f use. Delirium, dementia, psychotic, mood, anxiety, or sleep symptoms or a sexual d ysfunction may be caused by the combined effects of a general medical condition an d substance use (including medications). In such situations, both diagnoses (e.g., Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder) should be listed . If it is not possible to ascertain w hether the mental symptoms are due to a general medica l condition or are substance induced, the Not Othenvise Specified category may be used (see discussion below) . When, as often happens, the presentation of a Men tal Disorder Due to a General Medical Condition contains a m ix of different symptoms (e.g., m ood and anxie ty), it is generally desirable to assign a single diagnosis based on which symptoms predominate in the clinical presentation. In some s ituat ions, it is not possible to determine whether the mental symptoms are primary, due to a general medical condi tion, or substance induced. The Not Otherwise Specified category should be used in such situations.
293.89
Diagnostic Features
The essential feature of Catatonic Disorder Due to a General Medical Condition is the presence of catatonia that is judged to be due to the direct physiological effects of a general medical condition. Catatonia is manifested by any of the following: motoric immobility. excessive motor activity, extreme negativism or mutism, peculiar ities of vol untary movement, echola lia, or echopraxia (Criterion A). There must be evidence from the history, physical examination, or laboratory finding s that the catatonia is the direct physi ological consequence of a general medical condition (Criterion 8 ). The diagnos is is not g iven if the catalonia is better accounted for by another mental disorder (e.g., Manic Episode) (Criterion C) or if it occurs exclus ively during the course of a delirium (Criterion D).
Mental Disorders Due to a Ge neral Medical Condition Motoric immobility may be manifested by catalepsy (waxy fl exibility) or stupor. The excessive motor activity is apparen tly purposeless and is not influenced by external stimuli. There may be extreme negativism tha t is manifested by resistance to all instructions o r the maintenance of a rigid posture against attempts to be moved. Peculiarities of voluntary m ovem ent are manifested by the voluntary assumption of inappropriate or bizarre postures or by prominent grimacing. Echolalia is the pathological, parro llike, and apparen tly senseless repetition o f a word or phrase just spa-ken by another person. Echopraxia is the repetitive imitation of the movements of another person.
Recording Procedu re s
In recording Cata tonic Disorder Due to a General Medical Condition, the clinician should nole both the specific phenomenology of the disturbance and the identified gener.1l medical cond ition judged to be causing the d is turbance on Axis I (e.g., 293.89 Catatonic Disorder Due to Malignant Neoplasm of Brain). The ICD9-Ct-,'I code for the general medical condition (e.g., 191.9 malignant neoplasm of brain) should also be noted on Axis III . (See Appendix G (or a list of selected ICD-9-CM diagnostic codes for general medical conditions.)
Differentia l Diagnosis
A separate diagnosis of Catatonic Disorder Due to a General Medical Cond ition is not given if the cata tonia occurs exclusively during the course of a d elirium. If the ind ividual is curren tly taking neuroleptic medica tion, Medication-Induced Movement Disorders should be considered (e.g., abnormal positioning may be due to 'eurolepticInduced Acute Dystonia). Catatonic symptoms rna}' also be p resent in Schizophrenia and Mood Disorders. Schizophrenia, Catatonic Type, is distinguished by the absence of evidence of a general medical condition that is etiologically related to the ca tatonia, and by the presence of other symptoms characteristic of Sch izophrenia (e.g., delusions, hallucinations, disorga nized speech, negative symptoms). A Mood Disorder With Ca tatonic Features is likew ise differentiated by the absence of evidence of a general medical condition tha t is etiologicaU related to the ca tatonia, and y by the presence of symptoms that meet the criteria for a Major Depressive or Manic Episode.
310 .1
Diagnostic criteria for 293.89 Catatonic Disorder Due to ... [Indicate the General Medical Condition]
A. The presence of catatonia as manifested by motoric immobility, excessive motor activity (that is appa rently purposeless and not influ enced by external stimuli), extreme negativism or mutism, pecul iarities of voluntary movement, or echolal ia or echopraxia. B. There is evidence from the history, physical exam inat ion, or laboratory findings that the disturbance is t he direct physiological consequence of a genera l medica l condit ion.
C. The disturbance is not better accounted for by another mental disorder (e .g., a Manic
Episode). D. The disturbance does not occur exclusively during the course of a delirium . Coding note: Include the name of the general medical condition on Axis I, e.g., 293.B9 Catatonic Disorder Due to Hepatic Encephalopathy; also code the ge neral medical cond ition on Axis III (see Append ix G for codes).
188
The clinical presentation in a given individual may depend on the nature and localization of the pathological process. For example, injury to the fron tal lobes may yield s uch symptoms as lack of judgment or foresigh t, fa cetiousness, disinhibition, and euphoria. Right hemisphere strokes have often been shown. to evoke personality changes in association with unilateral s patial neglect, anosognosia (inability of the ind ividual to recognize a bodily or fun ctional defi cit such as the existence of hemi pa resis), motor impersistence. and other neurological d eficit s.
Subtypes
The particular personality change can be specified by indicating the symptom presentation that predominates in the clinical presentation : l abil e Type. This subty pe is used if the predominant feature is affective labili ty. Disinhibited Type. This subtyp e is used if the predominant fea ture is poor impulse control (e.g., as evidenced by sexual ind iscretions). Aggressive Type. This subtype is used if the predominant feature is aggres si\'e behavior. Apathetic Type. This subtype is used if the predominant feature is marked apathy and indifference. Paranoid Type. This subtype is used if the predominant feature is suspi ciousness or paranoid ideation. Other Type. Thi s subtype is for presentations not characterized by any o f the above subtypes. Combined Type. This subtype is used if more than one feature predominates in the clinical picture. Unspecified Type.
310.1
189 1
The associated physical examination findings, laboratory findings, and patterns of prevalence and onset reflect those of the neurological or other general medical condi tion involved.
Differential Diagnosis
Chronic general medical conditions associated w ith pain and disability can also be associa ted with changes in personality. The diagnosis of Personality Change Due to a General Medical Condition is given only if a direct pathophysiological mechanism can be established. Thi s diagnosis is not given if the change is due to a behavioral or psychological adjustment or response to a genera l medical condition (e.g., dependent behav iors that result from a need for the assistance of others foll owing a severe head trauma, cardiovascular disease, or dementia). Personality change is a frequent asscr cia ted feature o f a delirium or deme ntia. A separate diagnosis of Personality Change Due to a General Medical Condition is not given if the change occurs exclusivel}' during the course of a d elirium. However, the diagnOSiS of Personality Change Due to a General Medical Condition may be given in addition 10 the diagnOSiS of dementia if the personality change is a prominent part of the clinical presentation. Furthermore, the diagnosis of Personality Change Due to a General Medical Condition is not given if the disturbance is better accounted for by another Mental Disorder Due to a General Medical Cond ition {e.g., Mood Disorder Due to Brain Tumor, With Depressive Features}. Personality changes may also occur in the context of Substance Dependence, especially if the d ependence is long-standing. The clinician should inquire carefully about the nature and extent of substance use. If the clinician wishes to indicate an etiological relationship between the personality change and substance use, the Not Otherwise Specified category for Ule specific substance (e.g., Cocaine-Related Disorder Not Otherwise Specified ) can be used. Marked personality changes may also be an associated feature of other mental dIsorders (e.g., Schizophrenia, Delusional Disorder, Mood Disorders, lmpulse-Control Disorders Not Elsewhere Classified, Panic Disorder). However, in these disorders, no specific physiological factor is judged to be etiologically related to the personality change. Personality Change Due to a General Medical Condition can be distinguished from a Personality D isorder by the req uirement for a clinically significant change from baseline personality functi oning and the presence of a specific etiological general medical condition.
1 190
usual behavior patterns lasting at least 1 year), B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (including other Mental Disorders Due to a General Medical Condition).
D. The dirturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupat iona l, or other important areas of functioning.
Specify type:
Labile Type: if the predominant feature is affective lability Disinhibited Type: if the predominant feature is poor impulse control as evi denced by sexual indiscretions, etc. Aggressive Type: if the predominant feature is aggressive behavior Apathetic Type: if the predominant feature is marked apathy and indifference Paranoid Type: if the predominant feature is suspiciousness or paranoid ideation Other Type: if t he presentation is not characterized by any of the above subtypes Combined Type: if more than one feature predominates in the clinical picture Unspecified Type Coding note: Include the name of the general medical condition on Axis I, e.g., 310.1 Personality Change Due to Temporal Lobe Epilepsy; also code the general medica l condi t ion on Axis III (see Appendix G fo r codes).
293.9
This residual category should be used for situations in which it has been established that the d js turbance is caused by the direct physiological effects of a general medical condition, but the criteria are not met for a specific Mental Disorder Due to a General Medical Condition (e.g., dissociative symptoms due to complex partial seizures). Coding note: Include the name of the general medical condition on Axis L e.g., 293.9 Mental Disorder Not Otherwise Specified Due to HIV Disease; a lso code the general medical condition on Axis ill (see AppendiX G for codes).
Substance-Related Disorders
T he Substance-Related Oisorders include disorders related to the taking of a drug of abuse (induding alcohol), to the side effects of a medication, and to toxin exposure.
In this manual, the term substallce can refer to a drug of abuse, a medication, or a toxin. The substances discussed in this section are grouped into 11 classes: alcohol; amphetamine or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; p hencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, h ypnotics, or anxiolytics. Although these 11 classes
appear in alphabetical order, the follow ing classes share similar features: alcohol shares features with the sedatives, hypnotics, and anxiolytics; and cocaine shares features with amphetamines or similarly acting sympathomimetics. Also included in this section are Polysubstance Dependence and Other or Unknown Substance-Related Disorders (which include most disorders related to medications or toxins). Many prescribed and over~the+counter medications can also cause Substance+ Related Disorders. Symptoms generally occur at high doses o f the medication and usually disappear when the dosage is lowered or the medication is stopped . Med i ca~ nons that may cause Substance~Related Disorders include, but are not limited to, anesthetics and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medica tions, anti~ parkinsonian medications, chemotherapeutic agents, corticosteroids, gastrointes tinal medications, muscle relaxants, nons teroidal anti~inflammatory medications, other ove r-the~co unter medications, antidepressant medications, and disulfiram. Exposure to a wide range of other chemical substances can also lead to the development of a Substance+ Related Disorder. Toxic substances that may cause SubstanceRelated Disorders include, but are not limited to, heavy metals (e.g., lead or aluminum), rat poisons containing strychnine, pesticides containing nicotine, or acetyl cholin~ esterase inhibitors, nerve gases, ethylene glycol (antifreeze), carbon monoxide, and carbon dioxide. The vola tile s ubstances (e.g., fuel, paint) are classified as "inhalants" (see p. 257) if they are u sed for the purpose of becoming intoxicated; they are con~ sidered "toxins" if exposure is accidental o r part of intentional poisoning. impairments in cognition or mood are the most common symptoms associated with toxic subs tances, although anxiety, hallucinations, delusions, or seizures can also result. Symptoms usually disappear when the individual is no longer exposed to the s ub~ stance, but resolution of symptoms can take weeks or months and may require treatment. The Substance~Related Disorders are d ivided in to two groups: the Subs tance Use Disorders (Substance Dependence and Subs tance Abuse) and the Substance-Induced Disorders (Substance Intoxication, Subs tance WithdrawaL Subs tance~I nduced Delirium, Substance~Induced Persisting Dementia, Substance-Induced Persisting Am-
191
Substance-Related Disorders
nestic Disorder, Subs tan ce-Ind u ced Psychotic Disorder, Subs tance-Induced Mood Disorder, Substance-Induced Anxiety Disorder, Substance-Induced Sexu al Dysfunction, and Substance-Induced Sleep Disorder). The section begins w ith the text and criteria sets for Substance Dependence, Abuse, Intoxication, and W ithdrawal that are applicable across classes o f subs tances. This is followed by general comments concerning associated features; culture, age, and gender features; course; impaimlenl and complications; famili al pattern; differential diagnosis; and recording procedures that app ly to all s ubstance classes. The remainder of the section is organized by class of substance and describes the sp ecific aspects of Dependence, Abuse, Intoxication, and Wi thdrawal for each of the 11 classes of substances . It should be noted that the Prevalence sections of the substance-specific texts contain survey d ata ind ica ting rates of substance u se in variou s age groups, as well as the lifetime an d I-year prevalence of Dependence and Abuse. To facilitate differential diagnosis, the text and criteria fo r the remaining Substance-Induced Disorders are included in the sections of the manual w ith disorders w ith which they share phenomenology (e.g ., Subs tanceInduced Mood Disorder is included in the "Mood Disorders" section). The diagnoses associated with each specific g roup of substances are shown in Table 1.
Tab le 1.
-- - -- --
WithAmnestic P5ychotic M~d dra w a l Anx iety Delirium De m e ntia Disorde r Disorde rs Disorders Disorde rs
W
Sleep Disorders
IIW IIW I
,
0
~
~
Alcohol Amphe tamincs caffeine cannabis Cocaine Ha ll ucinogens In h;Jlants Nicotine Opioids Phencycli. d ine Sed;Jtives, hypnotics,
X X
X X
X X X
X X
I/W
I/W
IIW
I/W
"0
~
, a. ,
~
X X X X X X X X
X X X X
X X X
X X X
,
W
IIW
IIW
IIW
IIW
0,
;Jn~io lytics
X X X X X W
IIW
I/W
I/W
IIW
Also H;Jl1uci nogcn Persisting Perception Disorde r (Flashbacks). No te: X. I, W, Itw, or P indicates that the category is recognized in DSM-IV. In add itio n, I ind icates th;Jt the specifier With Onset During In t o~ication may be noted for the c;Jtegory (e~ccpt for I nto~i(i)t ion Delirium); W indicates that the specifier Wit h Onset During Wit hdrawal may be noted for the category (except for Withdrawal Delirum); and IIW indicates that either With Onset During Intoxication or Wi th Onset During Withdrawal may be noted for the ca tegory. P indicates that the d isorder is Persisti ng.
...
ID W
Substance-Related Disorders develop substantial (e.g., la-fold) levels of tolerance, often to a d osage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually less extreme than for amphetamine. Many individuals w ho smoke cigarettes consume more than 20 cigarettes a d ay, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis or phencyclidine (PCP) are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals) . Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents o r with other substances. In such situations, laboratory tests may be helpful (e.g., h igh blood levels of the substance coupled w ith little evid ence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished fro m individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drinks, whereas others of similar weight and drinking histories have slurred speech and incoordination. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the person is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms, which are generally the opposite of the acute effects of the substance, vary g reatly across the classes of substances, and separate criteria sets for \'Vithdraw al are provided for most of the classes. Marked and generally easily measured physiologica l signs of withdrawal are common w ith alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, w ith stimulants such as amphetamines and cocaine, as well as with nicotine and cannabis. No significant withdrawal is seen even after repea ted use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). N either tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. However, for most classes of substances, a past history o f tolerance or w ithdrawal is associated w ith a more severe clinical course (i .e., an earlier onset of Dependence, higher levels of substance intake, and a greater number of substance-related prob lems). Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without obvious signs of tolerance o r withdrawal. Conversely, some general medical and postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawa l symptoms w ithout showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Ph ysiological Dependence are provided to indicate the presence or absence of tolerance or withdrawal. TIle follOWing items describe the pattern of compulSive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many u nsuccessful efforts to decrease or discontinue use (Criterion 4).
Substance Dependence
195 1
The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person's daily activities revolve around the substance. Important social, occupational, or recrea tional activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from famil y activities and hobbies in order to use the substance in private or to spend more time with substance-using friend s. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g., severe depressive symptoms or damage to o rgan systems), the person continues to use the substance (Criterion 7). The key issue in evaluating this criterion is not the existence of the problem, but rather the individual's failure to abstain from using the substance despite having evidence of the difficulty it is causing.
Specifiers
Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence: With Physiological Dependence. This specifier should be used when Substance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulSive use (at least three items from Criteria 3-7).
Course Specifiers
Six course specifiers are available for Substance Dependence. The four Remission specifiers can be applied on ly after none of the criteria for Substance Dependence or Substance Abuse have been present for at least 1 month. For those criteria that require recurrent problems, a remission specifier can apply only if no aspect of the criterion has been present (e.g., one incident of driving while intoxicated would suffice to disqualify the individual from being considered in remission). The definition of these four types of Remission is based on the interval of time that has elapsed since the cessation of Dependence (Early versus Sustained Remission) and whether there is continued presence of one or more of the items included in the criteria sets for Dependence or Abuse (Partial versus Full Remission). Because the first 12 months following Dependence is a time of particularly high risk for relapse, this period is designated Early Remission. After 12 m onths of Early Remission have passed without relapse to Dependence, the person enters into Sustained Remission. For both Early Remission and Sustained Remission, a further designation of Full is given if no cri teria for Dependence or Abuse have been met during the period of remission; a designation of Partial is given if at least one of the criteria for Dependence or Abuse has been met, intennittently or continuously, during the period of remission. The differentiation of Sustained Full Remission from recovered (no current Substance Use Dis-
Substance-Re lated Disorders order) requires consideration of the leng th of time since the last period o f d isturbance, the total duration of the disturbance, and the need for continued evaluation. If, after a period of remission o r recovery. the individual again becomes d ependent, the application o f the Early Remission specifier requires that there again be at least 1 m onth in which no criteria fo r Dependence or Abuse are mel. Two additional specifiers have been p rovided: On Agonist Therapy and In a Controlled Environment. For an ind iv idual to q ualify fo r Early Remission after cessation of agonist therapy or release from a controlled environment, there m ust be a 1-month period in which none of the criteria for Dependence or Abuse are met. The following Remission specifiers can be ap plied only after no criteria for Depend ence or Abuse have been met for at least 1 month. Note that these specifiers do not apply if the indi vid ual is on agonist therapy or in a controlled en vironment (see below). Early Full Remission. This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.
_ Depende nce
Early Partial Remission. This specifier is used if, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Ab use have been met (but the full criteria for Depend ence have not been met).
_ Dependence
II,
---~II
Sustained Full Remission . This specifier is used if none of the criteria for Dependence or Abuse have been met at an y time d uring a period of 12 months or longer.
1 mo nth
11+ months
Substance Dependence
197 1
The (ollowing specifiers apply if the individual is on agonis t therapy or in a con* trolled e nvironment:
On Agonist Therapy. This specifie r is used if the indi vidual is on a prescribed agonist medication such as methadone and no criteria for Dependence or Abuse have been met for that class of medication for at least the pas t month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Depend ence using a partial agonis t or an agonist /
antagonist.
In a Controlled Environment.
environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past
month. Examples of these environments are closely supervised and substancefree jails, therapeutic communities, or locked hospital units.
198
Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission
On Agonist Therapy In a Controlled Environment
Substance Abuse
Features
The essential feature of Substance Abuse is a maladaptive pattem of substance use manifested by recurrent and significant advecseconsequences related to the repeated use of substances. In order for an Abuse criterion to be met, the substance-related problem must ha\'e occurred repeatedly during the same 12-month period or been persistent . There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physica lly hazardous, multiple legal problems, and recurrent social and interpersona l problems (Criterion A). Unlike the criteria for Substance Dependence, the criteria for Substance Abuse d o not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated use. A diagnosis of Substance Abuse is preempted by the d iagnosis of Substance Dependence if the individual's pattern of substance use has ever met the criteria for Dependence for that class of substances (C riterion B). Although a diagnOSis of Substance Abuse is more likely in individuals who have only recentJy started taking the substance, some individuals continue to have substance-related adverse social consequences over a long period of time without developing evidence of Substance Dependence. The category of Substance Abuse d oes not apply to caffeine and nicotine. The term abuse should be applied only to a pattern of substance use that meets the criteria for this disorder; the term should not be used as a synonym for "use," "misuse," or "haza rdous use." The individual may repeatedly demonstrate intoxication or other substance-related symptoms when expected to fu lfill major role obligations at work, school, or home (Criterion AI). There may be repeated absences or poor work performance related to recurren t hangO\'ers. A student might have substance-related absences, suspensions, or expulSions from school. While intoxicated, the individual may neglect children or household duties. The person may repea tedly be intoxica ted in situations that are
Substance-Induced Disorders
199
physicaUy hazardous (e.g., while driving a car, operating machinery, or engaging in risky recreational behavior such as swimming or rock climbing) (Criterion A2). There may be recurrent substance-related legal problems (e.g., arrests for disorderly conduct, assault and battery, driving under the influence) (Criterion A3). The person may continue to use the substance despite a history of undesirable persistent or recurrent social or interpersonal consequences (e.g., marital difficulties or divorce, verbal or physical fights) (Criterion A4).
Substance-Related Di sorde rs
mental d isorder (Criterion C). Substance Intoxication is often associa ted w ith Substance Abuse or Dependence. This ca tegory does nol apply to nicotine. Evidence for recent intake of the substance can be obtained from the history, physical examination (e.g., smell of alcohol on the breath), or toxicological ana lysis of body fluid s (e.g., urine or blood). The most common changes involve d isturbances o f perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior. The specific clinical picture in Substance Intoxication varies dramatically amon g ind ividuals and also depends on which substance is involved, the dose, the duration or chronicity of dosing, the person's tolerance for the substan ce, the period of time since the last dose, the expectations of the person as to the substance's effects, and the environmen t or setting in which the substance is taken. Short-term o r "acute" intoxications may have different signs and symptoms from sustained or "chronic" intoxications. For example, m oderate coca ine doses may initially produ ce g regariousness, bu t social w ithd.rawal may develop if such doses are frequently repeated over days or weeks. Different substances (sometimes even different substance classes) may produce identical symptoms. For example, Amphetamine and Cocaine Intoxication can both present w ith grandiosity and hyperactivity, accompanied by tachycardia, pupillary dilation, eleva ted blood pressure, and perspiration or chills. Also, alcohol and substances from the sedative, hypnotic, or anxiolytic class produce similar symptoms of intoxica tion. When used in the physiological sense, the term illfoxicafioll is broader than Substan ce Intoxication as defined h ere. Many substances may produce physiologica l or psychological changes that are not necessarily maladaptive. For example, an individual with tachycard.ia from excessive caffeine use has a physiological intoxication, but if this is the only sym ptom in the absence of maladaptive behavior, the d iagnosis of Caffeine Intoxication would not apply. The maladaptive nature of a substanceinduced change in behavior depends on the social and environmental con text. The maladaptive behavior genera lly places the individual at significant risk for adverse effects (e.g., accidents, genera l medical complications, dismption in social and family relationships, vocational or financial difficulties, legal problems). Signs and symptoms of intoxication may some times persist for hou rs or days beyond the time when the substance is detectable in body fluids. This rna }' be due to continuing low concentrations o f the substance in certain areas of the brain o r to a "hit and mn" effect in which the substance aJters a physiological process, the recovery of wh ich takes longer than the lime for elimination of the substance. These longer-term effects of intoxication must be distinguished from w ithdrawal (i .e., symptoms initia ted by a decline in blood or tissue concentrations of a substance).
20 2
tion in) substance use that has been heavy and pro longed.
B. Th e substance-speci fic syndro me causes cl inica lly sig nificant distress or impa irment in social, occupational. o r other importa nt a reas of fu nctioning_
C. The symptoms are not due to a genera l medical cond ition and are not better accounted f or by another mental d isorder.
Associated Feat ures of Substance Dependence, Abu se, Intoxication, and W ithdraw al
Assess ment issues. The d iagnosis of Substance Dependence requires obtaining a detailed history from the individual and , w henever possible, from addition al sources of informa tio n (e.g., m edical record s; a s pouse, re lative, or close frie nd). In addition, physica l examinatio n find ings and labo ra tory test results can be he lpful.
Route of administration . The route of adminis tration o f a s ubs ta nce is an important fa cto r in de terminin g its effects (including the tim e COluse of developing Intoxication, the probabili ty tha t its use will prod uce physio logical changes associa ted with W ithdrawa l, and the li kelihood tha t use w ill lea d to Depende nce o r Abuse). Ro utes of admin is tra tion tha t prod uce m o re rapid and e fficient abso r ptio n into the bloodstream (e.g ., intraven o us, sm oking, o r "sno rting ") tend to res ult in a more intense into xica tion and an increased likelihood of an escalating pattern of substance use leading to Dependence. These ro utes of administration quickly d eliver a large amount of the su bstance to the brain and, thus, are a ssoci ated w ith hig her leve ls of s ubstance consu mptjo n and an increased likelihood of toxic effects. For example, a person w ho uses intravenous a mphe tamine is more like ly to ra p idly consume large a m ounts of the substance a nd thereby ris k a n overdose than the person w ho o n ly ta ke s amp he tamine orally. Speed of onset within a class of substance. Rapidly acting su bstances are m ore likely than slower-ac ting s ubstances to produce imm ediate intoxicatio n and lead to Dependence or Abuse. Fo r examp le, because diazepam and a lpra zo lam both ha ve a m o re ra pid o nset than phe nobarbi ta l, they may co nseq uen tly be more like ly to lead to Subs tance Dep end ence o r Abuse. Duration of effects. The duratio n o f effects a ssocia ted w ith a pa r ticu lar s ubs tance is also impo rtant in de te rmining the tim e course of intoxication and w hether use of the subs tance w ill le ad to Dependence o r Abuse. Re la tively short-acting su bs tances (e.g., certain anxio lytics) tend to have a hig her p o ten tial fo r the developm e nt of Depen dence o r Abu se than s u bs tances with similar effects that h ave a longer dura tion of action (e.g., phenoba rbita l). The half-life o f the s ubs ta nce parallels a spects of Wi th-
204
Substance-Related Disorders
by h is tory or by toxicological analysis of body fluids (e.g., urine or blood). Although many substances and their metabolites clear the urine within 48 hours of ingestion, certain metabolites may be present for a longer period in those who use the s ubstance chronica lly . If the person presents with Withdrawal from an unknown substance, urine lesls may help identify the subs tance from which the person is withdrawing and make it possible to initiate appropriate treahnent. Urine tests may also be helpful in differentiating Withdrawal from other mental disord ers, because withdrawa l symptoms can mimic the symptoms of mental disorders unrelated to use of a s ubstance. In cases in which Opioid Dependence cannot be d early confirmed by history, the use of an antagonist (e.g., naloxone) to demonstrate whether withd rawal symptoms a re induced may be informative. Associated physica l examination fin dings and general medical conditi ons . As presented in the sections specific to the 11 classes of subs tance, intoxication and withdrawal states are likely to include physical signs and symptoms tha t are often the first clue to a subs tance-related s tate. In general. intoxica tion with amphetamines or cocaine is accompanied by increases in blood pressure, respiratory rate, pulse, and body temperature. Intoxication with sedative, hypnotic, or anxioly tic s ubstances or with opioid medication often involves the opposite pattern. Subs tance Depend ence and Abuse are often associated w ith general medical conditions often related to the toxic effects of the s ubstances on particular organ systems (e.g., cirrhosis in Alcohol Dependence) or the routes of adminis tration (e.g ., human imnumodeficiency virus [HIVJ infection from shared needles). Associated mental d isorders . Subs tance use is o ft en a component of the presentation of symptoms of mental disorders. When the symptoms are judged to be a direct physiological consequence of a subs tance, a Subs tance-Induced Disorder is diagnosed (see p. 209). Subs tance-Related Disorders are also commonly comorbid with, and complicate the course and treatment of, many men tal disorders (e.g., Conduct Disorder in adolescents; Antisocial an d Borderline Personality Disorders, Schizopluenia, Bipolar Disorder).
205
Heroin Dependence). If there are symptoms or problems associated with a particula r substance but criteria are not met for any of the substance-specific disorders, the I ot Otherwise Specified ca tegory can be used (e.g., 292.9 Cannabis-Related Disorder Not Otherwise Specified). If multiple substances are used, all relevant Substance-Related Disorders should be diagnosed (e.g., 292.89 Mescaline Intoxication; 304.20 Cocaine Dependence). The situations in whi", a diagnosis of 304.80 Polysubstance Dependence should be given are described on p. 293. For medications and toxins. For medications not covered above (as well as for toxins), the code for "Other Substance" should be used. The specific medication can be coded by also listing the appropriate E-code on Axis I (see Appendix G) (e.g., 292.89 Benztropine Intoxication; E941 .1 Benztropine). E-codes should also be used for classes of substances listed above when they are taken as prescribed (e.g., opioids).
Course
TIle cou rse of Depend ence, Abuse, lntoxication, and Withdraw al varies with the class of substance, rou te of administration, and other factors. The "Course" sections for the various classes of substances indica te the specific feature s characteristic of each. However, some genera lizations across substances can be made. lntoxica tion usuall y develops within minutes after a sufficien tly large single dose and continues or intensifies with freq uently repeated doses . In toxication begins to abate as blood or tissue concentrations of the substance decline, but signs and symptoms may resolve slowly. The onset of lntoxication may be delayed with slowly absorbed substances or w ith those that must be metabolized to active compounds. Long-acting substances may prod uce prolonged intoxications. Withdrawal develops with the decline of the substance in the central nervous sys-
206
tern. Early symptoms of Withdrawal usually develop a few hours after dosing stops
for substances with short elimina tion half-lives (e.g., alcohol, lorazepam, or heroin),
although withdrawal seizures may develop several weeks after termination of high doses of long-half-life anxiolytic substances. The more intense signs of Withdrawal usually end within a few days to a few weeks after the cessation of substance use, although some s ubtle ph ysiologica l signs may be delectable for many weeks or even months as part of a protracted withdrawal syndrome. For example, impaired sleep can be seen for months after a person with Alcohol Dependence stops drinking. A diagnosis of Substance Abuse is more likely in individuals who have begun using substances only recently. For many individuals, Substance Abuse with a particular class of substances evolves into Substance Dependence for the same class of substance. This is particuJarly true for those substances that have a high potential for the development of tolerance, withdrawal, and patterns of compulSive use such as cocaine o r heroin. Some individ uals have evidence of Substance Abuse that occurs over an extended period of time without ever developing Substance Dependence. nus is more true for those substances that have a lower potential for the development of tolerance, withdrawal, and patterns of compulsive use. Once criteria for Substance Dependence are met, a subsequent diagnosis of Substance Abuse cannot be given for any substance in the same class. For a person with Substance Dependence in full remission, any relapses that meet criteria for Substance Abuse would beconsidered Dependence in partial remission (see course specifiers, p. 195). The course of Substance Dependence is variable. Although rela tively brief and self-limited periods of Dependence may occur (particularly during times of psychosocial stress), the course is usually chronic, lasting years, with periods of exacerbation and partial or full remission. There ma y be periods of heavy intake and severe problems, periods of total abstinence, and times of nonproblematic use of the substance, sometimes lasting for months. Substance Dependence is sometimes associated with spontaneous, long-term remissions. For example, follow-ups reveal that 20% (or more) of individuals with Alcohol Dependence become permanently abstinent, usually following a severe life stTess (e.g., the threat or imposition of social or legal sanctions, discovery of a We-threatening medical complication). During the first 12 months after the onset of remission, the individual is particularly vulnerable to having a relapse. Many individuals underestimate their vulnerability to developing a pattern of Dependence. When in a period of remission, they incorrectly assure themselves that the)' will have no problem regulating substance use and may experiment with gradually less restrictive rules governing the use of the substance, only to experience a return to Dependence. The presence of co-occurring mental disorders (e.g., Antisocial Personality Disorder, untreated Major Depressive Disorder, Bipolar Disorder) often increases the risk of complications and a poor outcome.
Substance-Relat ed Disorde rs
inadequate personal hygiene. Intoxication or Withdrawal may be compUcated by trauma related to impaired motor coordination or faulty judgment. The materials used to "cut" certain substances can produce toxic or allergic reactions. Using substances intranasally ("snorting") may cause erosion of the nasal septum. Stimulant use can reswt in sudden death from cardiac arrhythmias, myocardial infarction, a cerebrovascular accident, or respiratory arrest. The use of contaminated needles during intravenous administration of substances can cause human immunodeficiency virus (HIV) infection, hepatitis, tetanus, vasculitis, septicemia, subacute bacterial endocarditis, embolic phenomena, and malaria. Substance use can be associated with violent or aggressive behavior, which may be manifested by fights or criminal activity, and can result in injury to the person using the substance or to others. Automobile, home, and industrial accidents are a major complication of Substance Intoxication and result in an appreciable rate of morbidity and mortality. Approximately one-half of all highway fata lities involve either a driver or a pedestrian w ho is intoxicated. In addition, perhaps 10% of individua ls with Substance Dependence commit suicide, often in the context of a Substance-Induced Mood Disorder. Finally, because most, if not all, of the substances described in this section cross the placenta, they may have potential adverse effects on the developing fetus (e.g., fetal alcohol syndrome). When taken repeatedly in high doses by the mother, a number of substances (e.g., cocaine, opioids, alcohol, and sedatives, hypnotics, and anxiolytics) are capable of causing physiological dependence in the fetus and a withdrawa l syndrome in the newbom.
Differential Diagnosis
Substance-Related Disorders are distinguished from non pathological su bstance use (e.g., "social" drinki ng) and from the use of medications for appropriate medical purposes by the presence of a pattem of multiple symptoms occurring over an extended period of time (e.g., tolerance, withdrawal, compulsive use) or the presence of substance-related problems (e.g., medical compL ications, disruption in social and family relationships, vocational or financial difficulties, legal problems). Repeated episodes of Substance Intoxication are almost invariably prominent features of Substance Ab use or Depend ence. However, one o r more episodes of lntoxication alone are not sufficient for a diagnosis of either Substance Dependence or Abuse.
Substance Withdrawal. If a symptom arises during the time of dosing and then gradually abates after dosing stops, it is likely to be part of Intoxication. U the symptom arises after stopping the substance, or reducing its use, it is likely to be part of Withdrawal. lndividuals w ith Substance-Related Disorders often take more than one substance and may be intoxicated with one substance (e.g., heroin) w hile withdrawing from another (e.g., diazepam). This differential is further complicated by the fact thai the signs and symptoms of Withdrawal from some substances (e.g., sedatives) may partially mimic Intoxication with o thers (e.g., amphetamines). Substance Intoxication is d ifferentiated from Substance Intoxication Delirium (p. 143), Substance-Induced Psychotic Disorder, With Onset During Intoxication (p. 338), Substance-Induced Mood D isorder, With Onset During Intoxication (p. 405), Substance-Induced Anxiety Disorder, With Onset During Intoxication (p. 479), Substance-Induced Sexual Dysfunction, With Onset During Intoxication (p. 562), and Substance-Induced Sleep Diso rder, With Onset During Intoxication (p. 655), by the fact that the symptoms in these latter disorders a re in excess of those usually associa ted with Substance Intoxication and are severe enough to warrant independent clinical attention. Substance Withdrawal is d istinguished from Substance Withdrawal Delirium (p. 143), Substance-Induced Psychotic Disorder, With Onset During Withdrawal (p. 338), Substance-Induced Mood Disorder, With Onset During Withdrawal (p. 405), Sub stance-Induced Anxiety Disorder, With Onset During Withdrawal (p. 479), and Substance-Induced Sleep Disorder, With Onset During Withdrawal (p. 655), by the fact that the symptoms in these latter disorders are in excess of those usually associated with Substance Withdrawal and are severe enough to warrant independent dinical attention. The additional Substance-Induced Disorders described above present w ith symptoms that resemble non-substa nce-induced (i.e., primary) m ental disorders. See p. 210 fo r a discussion of this important differential diagnosis. An additional diagnosis of a Substance-Induced Disorder is usually not made when symptoms of preexisting mental disorders are exacerbated by Substance Intoxication or Substance Withdrawal (although a diagnosis of Substance Intoxication or Withdrawal might be appropriate). For example, Intoxication w ith some substances may exacerbate the m ood swings in Bipolar Disorder, the auditory hallucinations and paranoid delusions in Schizophrenia, the intrusive thoughts and terrifying dreams in Posttraumatic Stress Disorder, and the anxiety symptoms in Panic Disorder, Generalized Anxiety Disorder, Social Phobia, and Agoraphobia. Intoxication or Withdrawal may also increase the risk of suicide, violence, and impulsive behavior in individuals with a preexisting Antisocial or Borderline Personality Disorder. Many neurological (e.g., head injuries) or metabolic conditions produce symptoms that resemble, and are sometimes misattributed to, Intoxication or Withdrawal (e.g., flu ctuating levels of consciousness, slurred speech, incoordination). The symptoms of infectious diseases may also resemble Withdrawal from some substances (e.g., viral gastroenteritis can be similar to Opioid Withdrawal). If the symptoms are judged to be a direct physiological consequence of a general medical condi tion, the appropriate Mental Disorder Due to a General Medical Condition should be diagnosed. U the symptoms are judged to be a direct physiological consequence of both substance use
209
and a genera l medical condition, both a Substance-Related Disorder and a Mental Disorder Due to a General Medical Condition may be diagnosed. If the clinician is unable to determine whether the presenting symptoms are substance induced, due to a general medical condition, or primary, the appropria te Not Othenvise Specifi ed Category should be diagnosed (e.g., psychotic symptoms with indetenninate etiology would be diagnosed as Psychotic Disorder Not Othen.... ise Specified).
Substance~ Related
Disorders
ders). Substance-induced presentations that develop in the context of Substance ln~ toxication can be indicated by using the specifier With Onset During lntoxication. Subs tance~induced presentations that develop in the context of Substance Withdrawal can be indicated by the specifier With Onset During Withdrawal. It should be noted that a diagnosis of a Substance-Induced Disorder, With Onset During Intoxication or \o\lithdrawal, should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome that is characteristic of the particular substance and when they are suffici ently severe to warrant independent clinical attention. For example, depression and fatigue that develop after stopping cocaine use following a prolonged period of daily intake are ordinarily diagnosed as Cocaine Wi thdrawal, since these symptoms are typical features of the withdrawal syndrome. Severe depression accompanied by a suicide attempt is usually diagnosed as CocaineInduced Mood Disorder, With Depressive Features, With Onset Ouring Withdrawal, since a suicidal depression is in excess of what is usually seen in Cocaine Withdrawal and would warrant independent clinical attention. Three Substance-Induced Persisting Disorders are included: Substance-Induced Persisting Dementia (see p. 168) and Substance-Induced Persisting Amnestic Disorder (see p. 177) in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section and Hallucinogen Persisting Perception Disorder under "Halluci nogen-Related Disorders" in this section (see p. 253). The essential feature of a Substance-Induced Persisting Disorder is prolonged or permanent persistence of substance-related sy mptoms that continue long after the usual course of Intoxication or Withdrawa l has ended. For drugs of abuse, a diagnosis of a Substance-Induced Mental Disorder requires that there be evidence from the history, physical examination, or laboratory findings of Substance Intoxication or Substance Withdrawal. In evaluating whether the symptoms of a mental disorder are the direct physiological effect of substance use, it is important to note the temporal relationship between the onset and offset of substance use and the onset and offset of the symptoms or the full syndrome. If the symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced . As a rule of thumb, symptoms that persist for more than 4 weeks after the cessation of acute Intoxication or Withdrawal should be considered to be manifestations of an indepen~ d ent non-substance-induced mental disorder or of a SubstanceInduced Persisting Disorder. Clinical judgment is necessary in making this distinction, particularly because different substances have different characteristic durations of intoxication and withdrawal and varying relationships with symptoms of mental disorders. Because the withdrawal state fo r some substances can be relatively protracted, it is useful to carefully observe the course of symptoms for an extend ed period of time (e.g., 4 weeks or more) after the cessation of acute Intoxication or Withdrawal, making all possible efforts to maintain the individual's abstinence. This can be accomplished in various ways, including inpatient hospitalization or residential treatment, requiring frequent follow~up visits, recruiting friends and family members to help keep the person substance free, regularly evaluating urine or blood for the presence of substances, and, if alcohol is involved, routinely evaluating changes in sta te markers of heavy drinking such as gamma-glu tamyltransferase (GCn.
211
Another consideration in differentiating a p rimary mental disorder from a SubstanceInduced Disorder is the presence of features that are atypical of the primary disorder (e.g., atypical age at onset or cou rse). For example, the onset of a Manic Episode after age 45 years may suggest a subs tance-induced etiology. In contras t, factors that s uggest that the sym ptoms are better accounted for by a primary mental d isorder include a history of prior episod es o f the disturbance that were not substance induced . Finally, the presence or absence of the s ubs tance-specific ph ysiological and behavioral features of Intoxication or Withdrawal s hould be considered . For example, the presence of paranoid delusions would not be s urprising in the context of Amphetamine Intoxication, but would be unusual with Sedative Intoxication, increasing th e likelihood that a primary Psychotic Disorder accounts for the sym ptoms. Furthermore, the dosage of the s ubs tance used should be taken into account. For example, the presence of paranoid d elusions would be unus ual after a single puff of marijuana, but might be compatible w ith high d oses of hashish. Subs tance-Ind uced Disorders can also occur as a side effect of a med ication or from expos w e to a toxin. Substance-Induced Disorders due to a prescribed treahnent fo r a mental diso rder or general medical condition mus t have their onset while the person is receiving the medication (or during withdrawal if the medication is associated with a withdrawal syndrome). Once the treatment is d iscontinued, the symptoms will usuaUy remit within days but may p ersist fo r up to 4 weeks or so (depending on the halflife of the subs tance, the presence of a withdrawal synd rom e, and individual variability). If symptoms persist, a primary mental disorder (not related to a medication) should be considered. Because ind ividuals w ith general medical conditions often take medications for those conditions, the clinician mus t consider the possibility that the symptoms are caused by the physiological consequences of the general medical condition rather than the medkation, in which case Mental Disorder Due to a General Medical Condition is diagnosed. The his tory may provide a basis for making this judgm ent, but a change in the treatment for the general medical condition (e.g., medication subs titution or d iscon tinuation) may be needed to determine empirically for that person whether or n ot the medication is the causative agent.
Recording Procedures for Substance-Induced Mental Disorders Included Elsewhere in the Manual
The name of the d iagnosis begins w ith the sp ecific substance (e.g., cocaine, diazepam, dexamethasone) that is presumed to be causing the symptoms. The d iagnostic code is selected fro m the lis ting of classes of s ubstances provided in the criteria sets for the particular Substance-Induced Disord er. For s ubs tances that do not fit into any of the classes (e.g ., dexamethasone), the code for "Other Substance" s hould be used. In addition, for medications prescribed at therapeutic d oses, the s pecific medication can be indicated by listing the appropriate E-code on Axis I (see Append ix G). The name of the disorder (e.g., Cocaine-Induced Psychotic Disorder; Diazepam-Ind uced Anxiety Disorder) is fo llowed by the s pecification of the predominant symptom presentation and the context in which the symptoms developed (e.g., 292.11 Cocaine-Induced Psychotic Disorder, With Delusions, With Onset During Intoxica tion; 292.89 DiazepamInduced Anxiety Disorder, With Onset During Withdrawal). When more than one substance is judged to play a Signifi cant role in the development of symptoms, each
Alcohol-Related Disorders
In most cultures, alcohol is the most hequently used brain depressant and a cause of considerable morbidity and mortality. At some time in their lives, as many as 90% of ad ults in the United States have had some experience with alcohol, and a substantial number (60% of males and 30% of females) have had one or more alcohol-related adverse life events (e.g., driving after consuming too much alcohol, missing school or wo rk due to a hangover). Fortunately, most individuals learn from these experiences and modera te their drinking, thus avoiding Alcohol Dependence or Abuse. This section contains d iscussions specific to the Alcohol-Related Disorders . Texts and criteria sets have alread y been provided earlier for the generic aspects of Substance Dependence (p . 192) and Substance Abuse (p. 198) that apply across all substances. The application of those general criteria to Alcohol Dependence and Abuse is provided below . However, there are no additional unique criteria sets for Alcohol Dependence or Alcohol Abuse. Specific texts and criteria sets for Alcohollntoxication and Alcohol Withdrawal are also provided below. The Alcohol-Induced Disorders (other than Alcohol Intoxica tion and Withdrawal) are described in the sections of the manual w ith diso rders with which they share phenomenology (e.g., Alcohol-Ind uced Mood Disorder is included in the "Mood Disorders" section). Listed helow are the Alcohol Use Disorders and the Alcohol-Induced Disorders.
Alcohol-Induced Disorders
303.00 291.81 291.0 291.0 291.2 291.1 291.5 Alcohollntoxication (see p. 214) Alcoh ol Withdrawal (see p. 215) Specify if: With Perceptual Disturbances Alcohol Intoxication Delirium (see p . 143) Alcohol Withdrawal Delirium (see p . 143) Alcohol-Induced Persisting Dementia (see p. 168) Alcohol-Induced Persisting Amnestic Disorder (see p. 177) Alcohol-Induced Psychotic Disorder, With Delusions (see p. 338) Specify if; With Onset During Intoxicatjon / With Onset During Withdrawal
303.90
213
291.89
291.89
291.89 291.89
291.9
Alcohol-Induced Psychotic Disorder, With Hallucinations (see p . 338) Specify if: With Onset During intoxication/ With Onset During W ithdrawal Alcohol-Induced Mood Disorder (see p. 405) Specify if: With Onset During Intoxication / With Onset During Withdrawal Alcohol-Induced Anxiety Disorder (see p. 479) Specify if: With Onset During Intoxication / With Onset During Withdrawal Alcohol-Induced Sexual Dysfunction (see p. 562) Specify if; V'lith Onset During Intoxication Alcohol-Induced Sleep Disorder (see p. 655) Specify if: With Onset During Intoxication / With Onset During Withdrawal Alcohol-Related Disorder Not Othenvise Specified (see p. 223)
Refer, in addition, to the general text and criteria for Substance Dependence (see p. 192). Physiological dependence on alcohol is indicated by evidence of tolerance or symptoms of Withdrawal. Especially if associated w ith a history of withdrawaL physiological dependence is an indication of a more severe clinical course overall (i.e., earlier onset, higher levels of intake, more alcohol-related problems). Alcohol Wi thdrawa l (see p. 215) is characterized by withdrawal symptoms that develop 4-12 hours or so after the reduction o f intake following prolonged, heavy, alcohol ingestion. Because Withdrawal from alcohol can be unpleasant and intense, individuals with Alcohol Dependence may continue to consume alcohol, d espite adverse consequences, often to avoid or to relieve the symptoms o f withdrawal. Some withdrawal symptoms (e.g., sleep problems) can persist at lower intensities for months. A subs tantia l minority of individuals who have Alcohol Dependence never experience clinically relevant levels of Alcohol Wi thdrawal, and only about 5% o f individuals with Alcohol Dependence ever experience severe complications of withdrawal (e.g., delirium, grand mal seizures). Once a pattern of compulsive use develops, individuals w ith Dependence may devote substantial periods of time to obtaining and consuming alcoholic beverages. These individuals often continue to use alcohol despite evidence of adverse psychological or physical consequences (e.g., depression, blackouts, liver disease, or other sequelae).
Specifiers
The following specifiers may be applied to a diagnosis of Alcohol Dependence (see p. 195 for more details): With Physiological Dependence Without Physi ological Dependence Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission In a Co ntrolled En vironm ent
305.00
Alcohol Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p. 198). Alcohol Abuse requires fewer symptoms and, thus, may be less severe than Dependence and is only diagnosed once the absence of Dependence has been established. School and job performance may suffer either from the aftereffects of drinking or from actual intoxication on the job or at school; child care or household responsibilities may be neg lected; and alcohol-rela ted absences may occw from school or job. The person may use alcohol in physically hazardous circumstances (e.g., driving an automobile or 01>"' erating machinery while intoxicated). Legal difficulties may arise because of alcohol use (e .g., arrests for intox icated behavior or for driving under the in flu ence). Finally, individuals with Alcohol Abuse may continue to consume alcohol despite the knowledge that continued consumption poses Significant social or interpersonal problems for them (e.g., violent arguments with spouse while intoxicated, child abuse). When these problems are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to alcohol use, a diagnosis of Alcohol Dependence, rather than Alcohol Abuse, should be considered. However, since some symptoms of tolerance, withdrawal, or compulsive use can occw in individuals with Abuse but not Dependence, it is important to determine whether the full criteria for Dependence are met.
Alcohol-Induced Disorders
303.00
Alcohol Intoxication
Refer to the text and criteria for Substance Intoxication (see p . 199). The essential fea ture of Alcoh ol Intoxication is the presence of clinically Signi ficant maladaptive behavioral or psychological changes (e.g., inappropriate sexual o r aggressive behavior, mood lability, impaired judgment, impaired social or occupational functi oning) that develop during, or shortly after, the ingestion of alcohol (Criteria A and B) . These cha nges are accompanied by evidence of slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, or stupor or coma (Criterion C). The symptoms must not be due to a general medical condition and are no t better accounted for by another mental disorder (Criterion D). The resulting picture is similar to what is observed during Benzodiazepine or Barbiturate Intoxication. The levels of
29 1.81
215
incoordin ation can interfere with driving abilities and with performing usual activities to the point of causing accidents. Evidence of alcohol use can be obtained by smelling alcohol on the in d ividual's breath, eliciting a history from th e individual or another observer, and, when needed, having the individual undertake breath, blood, or urine toxicology analyses.
slurred speech incoordination unsteady ga it nystagmus impair ment in attention or memory stupor or coma
O. The symptoms are not due to a general med ical condit ion and are not better accounted for by another m ent al disord er.
2 91.81
Alcohol Withdrawal
Refer, in addition, to the text and criteria for Substance Withdrawa l (see p. 201). The essential feature of Alcohol Withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of (or reduction in) heavy and prolonged alcohol use (Criteria A and B). The withdrawal syndrome includes two or more of the following symptoms: autonomic hyperactivity (e.g ., sweating or pulse rate greater than 100); increased hand tremor; insomnia; p sychomotor agitation; anxiety; nausea or vomiting; and, rarely, grand mal seizures or transient visual, tactile, or auditory hallucinations or illusions. \Vhen hallucinations or illusions aTe observed, the clinician can specify With Perceptual Disturbances (see below). Withdrawal symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (C riterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (e.g ., Sedative, Hypnotic, or Anxiolytic Withdrawal or Generalized Anxiety Disorder) (Criterion D). Symptoms can be relieved by administering alcohol or any other brain depressant. The withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been stopped or reduced. Because of the sho rt half-life of alcohol, symptoms of Alcohol W ithdrawal usua ll y peak in intensity during the second day of abstinence and are likely to improve mark-
216
Substance-Related Disorders
cdly by the fourth or fifth day. FoUowing acu te Withdrawal. however, symptoms of anxiety, insomnia, and autonomic d ysfunction may persist for up to 3-6 months at lower levels of intensity. Fewer than 10% of individuals who develop Alcohol Withdrawal will ever devel op dramatic symptoms (e.g., severe autonomic hyperactivity, tremors, and Alcohol Withdrawal Delirium). Grand mal seizures occur in fewe r than 3% of individua ls. Alcohol Withdrawal Delirium (p. 143) includes dis turbances in consciousness and cognition and visual, tactile, or auditory hallucinations ("d elirium tremens," or " DTs"). When Alcohol Withdrawal Delirium develops, it is likely that a clinically relevant general medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, an electrolyte imbalance, or postoperative status).
Specifier
The following specifier may be applied to a diagnosis of Alcohol Withdrawa l: With Perceptual Disturbances. This specifier may be noted in the rare instance when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent extema l reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, should be considered .
(3) Insomn ia
(4) nausea or vomiting
C. The symptoms in Criterion B cause clinically significant distress or impairme nt in social, occupational, or other important areas of function ing. D. The symptoms are not due to a general medical condition and are not better accounted for by another ment al disorder.
Specify if:
217
218
Substance+Related Disorders
within their jobs. Mood Disorders, Anxiety Disorders, Schizophrenia, and Antisocia l Personality Disorder may be associa ted with Alcohol Dependence. It should be noted that some evidence suggests tha t at least a part of the reported association behveen depression and Alcohol Dependence may be attributable to comorhid depreSSive symptoms resulting from the acute effects of intoxication or wi thdrawal.
Associated laboratory findings . One sensitive laboratory indicator of heavy drinking is an eleva tion (>30 units) of gamma-glutamyltransferase (GCn. This finding may be the only laboratory abnormality. At least 70% of individuals with a high GGT level are persis tent heavy drinkers (i.e., consuming eight or more drinks daily on a regular ba sis). A second test with comparable or even higher levels o f sensitivity and specificity is carbohydrate deficient transferrin (C On, with levels of 20 units or higher useful in identifying individuals w ho regularly consu me eight or more drinks daily. Since both GGT and COT levels retum toward normal w ithin days to weeks of s topping drinking, both s tate markers are useful in monitoring abstinence, especially w hen the clinician observes increases, rather than decreases, in these values over time. The combination of COT and GGT may have even higher levels of sensitivity and speci fi city than either test used alone. Additional useful tes ts include the mean corpuscular volume (lvICV), which may be elevated to high-normal va lues in individua ls who drink heavily- a ch ange that is due to the d irect toxic effects of alcohol on erythropoiesis. Although the MCV can be used to help identify those w h o drink heavily, it is a poor method of monitoring abstinence because of the long half-life of red blood cells. liver hmction tests (e.g., alanine aminotransferase IALT] and alkaline phosphatase) can reveal liver injury that is a consequence of heavy drinking. Elevations of lipid levels in the blood (e.g., triglycerides and lipoprotein cholesterol) can be observed, resu lting from decreases in gluconeogenesis associated with heavy dri nking . High fat content in the blood also contributes to the development of fatty liver. High-nonnal levels of uric acid can occur with heavy drinking, but are relatively nonspecific. The most direct test available to measure alcohol consumption crosssectionally is blood alcohol con centration, w h ich can also be used to judge tolerance to alcohol. An individual with a concentra tion of 100 mg of ethanol per deciliter of blood w ho does not show signs of intoxication can be presumed to have acquired at least some degree of tolerance to alcohol. A t 200 mg/ d L, most nontolerant individuals demonstrate severe intoxica tion . Associated physical examination findings and general medical conditions. Repeated intake of high d oses of alcohol can affect nearly every organ system, especially the gastrointestinal tract, card iovascular system, and the central and peripheral nervous systems. Gastroin testinal effects include gastritis, stomach or duodena l ulcers, .1fld, in abou t 15% of those who use alcohol heavily, liver cirrh osis and pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract. One of the mos t common associated general medical conditions is low-grade hypertension. Cardiomyopathy and other myopathies are less common, but occur at an increased rate among those who drink very heavily. These factors, along with marked increases in levels of triglycerides and low-density lipoprotein cholesterol, contribute to an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased
219
peripheral sensation. More persistent central nervous system effects include cognitive deficits, severe memory impairment, and degenerati ve changes in the cerebel lum. These effects are related to the direct effects of alcohol or of trauma and to vitamin deficiencies (particularly of Ule B vitamins, including thiamine). One devastating central nervous system effect is the relatively rare Alcohol-lnduced Persis ting Amnestic Disorder (p. 177) (Wemicke-Korsakoff syndrome), in which the ability to encode new memory is severely impaired . M.my of the symptoms and physical findings associated w ith the Alcohol-Related Disorders are a consequence o f the di sease states noted above. Examples are the d yspepsia, nausea, and bloating that accompany gastritis and the hepa tomegaly, esophageal varices, and hemorrhoid s that accompany alcohol-induced changes in the liver. Other physical signs include tremor, lmsteady gait, insomnia, a.nd erectile dysfunction. Men with chronic Alcohol Dependence may exhibit decreased testicular size and feminiz ing effects associated w ith reduced testosterone levels. Repeated heavy drinking in women is .1ssociated with menstrual irregularities and, duri.ng p regnancy, with spontaneous abortion and fetal alcohol syndrome. Individuals w ith preexis ting histories of epilepsy or severe head trauma are more likely to develop alcohol-related seizures. Alcohol Withdrawa l may be associated w ith nausea, vomiting, gastritis, hematemesis, d ry mou th, puffy blotchy complexion, and mild peripheral edema. Alcohol Intoxication may res ult in fall s and accidents that may cause fractures, subdural hematomas, and other forms of brain trauma. Severe, repeated Alcohol Intoxication may also suppress immlme mechanisms and predispose individuals to infections and increase the risk for cancers. Finally, wmnticipated Alcohol Withdrawal in hospi talized patients for whom a diagnosis of Alcohol Dependence has been overlooked call add to the risks and costs of hospitalization and to time spent in the hos pital.
220
Substance-Related Disorders
in delennining risk as completing the immediate educational goal (i.e., those who drop ou l of high school or college have particularly high ra les of Alcohol-Rela ted Disorders). Among adolescents, Conduct Disorder and repeated antisocial behavior often cooccur with Alcohol Abuse or Dependence and with other Subs tance-Related Disorders. Age-related physica l changes in elderly persons result in increased brain susceptibility to the depressant effects of alcohol, decreased rales of liver metabolism of a variety of subs tances, including alcohol, and decreased percentages of body water. These
changes can cause older people to develop more severe intoxication and subsequent problems at lower levels of consumption. Alcoh ol-rela ted problems in older people are also especially likely to be associated with other medical complications. Females tend to develop higher blood alcohol concentrations than males at a gi ven dose of alcohol per kilogram because of their lower percentage of body water, higher percentage of body fat, and the fact that they tend to metabolize alcohol more slowly (in part because of lower levels of alcohol dehydrogenase in the mucosal lining of the stomach). Because of these higher alcohol levels, they may be at greater ri sk than males for some of the health-related consequences of heavy alcohol intake (in particular, liver damage). Alcohol Abuse and Dependence are more common in males than in females, with a male-to-female ratio as high as 5:1 , but this ratio varies substantially depending on the age group. In general, females sta rt to drink several years later than males, but once Alcohol Abuse or Dependence develops in females, the disorder appears to progress somewhat more rapidly. However, the clinical course of Alcohol Dependence in males and fema les is more similar than different.
Preva lence
Alcohol lise is highly prevalent in most Western countries, with the 199~ per capita consumption in adults in the United States estimated at 2.1 7 gallons of absolute alcohol. Among adults in the United States, two-thirds to 90% have ever consumed alcohol, depending on the sun'ey and the methods used, with figures for men higher than those for women. A 1996 national survey indicated that about 70% of men and 60% of women consumed alcohol, figures that varied with age, with the highest prevalence (77%) for those between ages 26 and 34 years. Higher proportions of drinkers were reported in tuban and coasta l areas of the United States, and there were only modest differences across racial groups. It should be noted that because these sun'eys measured patterns of use rather than disorders, it is not known how many of those in the sun'eys who used alcohol had symptoms that met criteria for Dependence or Abuse. Perhaps reflecting differences in research methodology and changes in the diagnostic criteria over the years, estimates of the prevalence of Alcohol Abuse and Dependence have varied markedly across different studies. However, when DSM-ITf-R and OSM-rv criteria a re used, it appears that in the mid1 990s, the lifetime risk for Alcohol Dependence was approximately 15% in the general population. The over.ll1 rate of curren t Alcohol Dependence (meastued as individuals whose pattern of alcohol use fulfilled the criteria over the prior year) probably approached 5%.
Alcohol-Relat ed Disorders
221
Course
The firs t episode of Alcohol Intoxication is likely to occur in the mid-teens, with the age at onset of Alcohol Dependence peaking in the 20s to mid-30s. The large majority of those who develop Alcohol-Related Disorders do so by thei r late 30s. The firs t e vidence of Withdrawal is not likely to appear until after many other ,1spects of Dependence ha ve developed . Alcohol Abuse and Dependence have a variable course tha t is freque ntly characterized by p eriods of remission and relapse. A decis ion to stop drinking, often in response to a crisis, is likely to be followed by weeks or more of abstinence, which is often followed by limited periods of controlled or nonproblematic drinking. H owever, once alcohol intake resumes, it is highly likely that conslUnption will rapidly escalate and that severe problems w ill once again develop. Clinicians often have the erroneous impression that Alcohol Dependence and Abuse are intractable disorders based on the fac t that those w h o present for treatment typically have a history of many years of severe alcohol-related problems. H owever, these most severe cases represent only a small proportion of individuals w ith Alcohol Dependence or Abuse, and the typical person with an Alcohol Use Disorder has a much more promising prognosis. Follow-up studies of more highly ftmc tioning individuals show a higher than 65% 1-year abstinence rate following treatment. Even among less ftmctional and homeless individuals with Alcohol Dependence who complete a treatment program, as many as 60% are abstinent a t 3 months, and 45"/0 at 1 year. Some individuals (perhaps 20% or more) w ith Alcohol Dependence achieve long-term sobriety even w ithout active treatment. During even mild Alcohol intoxication, diffe rent symptom s are likely to be observed at different time points. Early in the drinking period, when blood alcohol levcis are rising, symptoms often include talkativeness, a sensation of well-being, and a bright, expansive mood. Late r, especially when blood a1cohollevels are falling, the indi vidual is likely to become progressively more depressed, withdrawn, and cognitively impaired . At very high blood alcohol levels (e.g ., 200-300 mg/ d L), a nontolerant individual is likely to fall asleep and enter a first stage of anesthes ia. Higher blood alcohol level s (e.g., in excess of 300-400 mg/ dL) can cause inhibition of respiration and pulse and e ven death in nontolerant individuals. The duration of intoxication depends on how much alcohol was consumed over what period of time. in general, the body is able to metabolize approximately one drink per hour, so that the blood alcohol level generally decreases a t a rate of 15--20 mg / dL per hour. Signs and symptoms of intoxication are likely to be more intense when the blood alcohol level is rising than when it is falling.
222
Substance-Related Disorders
dence. Adoption studies have revealed a three- to fourfold increase in risk for Alcohol Dependence in the children of individuals with Alcohol Dependence when these children were adopted away at birth and raised by adopti ve parents who d id not have
this disorder. However, genetic fa ctors explain only a part of the risk for Alcohol Dependence, with a significan t pari of the risk coming from environmental or interpersonal fac tors that may include cultural atti tudes toward drinking and drunkenness, the availability of alcohol (including price), expectations of the effects of alcohol on mood and behavior, acquired personal experiences with alcohol, and stress.
Differential Diagnosis
For a general discussion of the differential diagnosis ofSubsfance-Related Disorders, see p . 207. Alcohol-Induced Disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental diso rders (e.g., ~'I ajor Depressive Disorder versus Alcohol-Induced Mood Disorder, With Depressive Features, With Onset During Intoxication). See p. 210 for a discussion of this differential diagnosis. The incoordination and impaired judgment that are associated with Alcohol lntoxkation can resemble the symptoms of certain gen eral medical condition s (e.g., diabetic acidosis, cerebeUar ataxias, and other neurological conditions such as multiple sclerosis). Similarly, the symptoms of Alcohol Withdrawal can also be mimicked by ce rtain general m edical conditions (e.g., h ypoglycemia and diabetic ketoacidosis). Essential tremor, a disorder that frequen tly runs in families, may suggest the tremulousness associated with Alcohol Withdrawal. Alcohol Intoxication (except for the smell of alcohol on the breath) closely resembles Sedative, Hypnotic, or Anxiolytic Intoxica tion . The presence of alcohol on the brea th does not by itself exclude intoxica tions with other substances because multiple substances are not uncommonJy used concurrently. Although intoxication at some time during their lives is likely to be a part of the his tory of most individuals who drink alcohol, when this phenomenon occurs regul arly or causes impairment it is important to consider the possibili ty of a diagnosis of Alcohol Dependence or Alcohol Abuse. Sedative, Hy pnotic, or Anxiolytic Withdrawal produces a syndrome very similar to tha i of Alcohol Withd rawal. Alcohol Intoxication and Alcohol Withdrawal are dis tinguished from the other Alcohol -In duced Disord ers (e.g., Alcohol-Induced Anxiety Disorder, W ith Onset During Withdra wal) because the symptoms in these latter disorders are in excess of those usually associated w ith Alcohol Intoxication or Alcohol Withdrawal and are severe enough to warrant independent clinical attention. Alcohol idiosyncratic intoxica tion, defined as marked behavioral change, usually ag gressiveness, following the ingestion of a relatively s mall of amount of alcohol, was included in OSM-Tn-R. Because of limited support in the literature for the validity of this condition, it is no longer included as a separate diagnosis in OSM-IV. Such presentations would most likely be d iagnosed as Alcohol Intoxication or Alcohol-Related Disorder Not Otherw ise Specified .
291.9
223
The class of amphetamine and amphetam ine-like substances includes all substances with a substituted-phenylethylamine structure, such as amphetamine, dextroamphetamine, and methamphetamine ("speed "). Also induded are those substances that are strucruraIly different but also have amphetamine-like action, such as methylphenidate o r agents used as appetite suppressants ("diet pills"). These substances a re usually taken ora lly or intravenously, although methamphetamine is also taken by the nasal route ("snorting" ). A very pure form of methamphetamine is called "ice" because of the appearance of its crystals when observed under magnification. Because o f its high purity and relatively low vaporization point, as is true for "crack," ice can be smoked to produce an immediate and powerful stimulant effect. In addi tion to the synthetic amphetamine-like compound s, there arc narurally occurring, plant-derived stimulants such as khat that can prod uce Abuse or Dependence. Unlike cocaine, wh ich is almost always purchased on the illegal market, amphetamines and other stimulants may be obtained by prescription for the treatment of obesity, AttentionDeficit/ Hyperactivity Disord er, and arcolepsy. Prescribed stimulants have sometimes been diverted into the illegal market, often in the con text of weight-control programs. Most of the effects of amphetamines and amphetamine-like drugs are similar to those of cocaine. However, unlike cocaine, these substances do not have local anesthetic (Le., membrane ion channel) activity; therefore, their risk for indUCing certain general medical conditions (e.g., cardiac arrhythmias and seizures) may be lower. The psychoactive effects of most amphetamine-like substances last longer than those of cocaine, and the peripheral sympathomimetic effects may be more potent. n,is section contains d iscussions that are specific to the Amphetamine-Rela ted Disorders. Texts and criteria sets have already been provided for the generic aspects of Substance Dependence (p. 192) and Substance Abuse (p. 198) that apply across all substances. The applkation of these general criteria to Amphetam ine Dependence and Ab use is provided below. H owever, there are no unique criteria sets for Amphetamine Dependence or Amphetamine Abuse. Specific texts and criteria sets for Amphetamine In toxication and Amphetamine Withdrawal are also provided below. The Amphetamine-Induced Disorders (other than Amphetamine in toxication and With-
Substance-Related Disord ers draw al) are described in the sections o f the manual w ith disorders with w hich they share phenomenology (e.g., Amphetamine-Induced Mood Disorder is included in the "Mood Disorders" section). Listed below are the Amphetamine Use Disorders and the Am phetamine-induced Disorders.
Amphetamine-Induced Disorders
292.89 292.0 292.81 292.11 292.12 292.84 Amphetamine Intoxica tion (see p. 226) Specify if: With Perceptual Disturbances Amphetamine Withdrawal (see p. 227) Amphetamine Intoxication Delirium (see p. 143) Amphetamine-Induced Psychotic Disorder, With Delusions (see p. 338) Specify if: With Onset During Intoxication Amphetamine-Induced Psychotic Disorder, With Hallucinations (see p . 338) SpecijeJ if: With Onset During Intoxication Amphetamine-Induced Mood Disorder (see p. 405) Specify if: With Onset During intoxication / With Onset During WiU,drawal Amphetamine-Induced Anxiety Disorder (see p. 479) Specify if: With Onset During intoxication Amphetamine-Induced Sexual D ysfunction (see p. 562) Specify if: With Onset During Intoxication Amphetamine-Induced Sleep Disorder (see p. 655) Specify if: With Onset During Intoxica tion / With Onset During Withdrawal Amphetamine-Related Disorder No t Othenvise Specified (see p. 231)
292.9
304.40
Amphetamine Dependence
Refer, in addition, to the text and criteria for Substance Dependence (see p. 192). The patterns of u se and course o f Amphetamine Dependence are similar to those of Cocaine Dep endence because both substances are potent central nervous system stimulants with similar p sychoactive and sympathomimetic effects. However, amphetamines are longer acting than cocaine and thus are usually self-administered fewer times per day. As wi th Cocaine Dependence, usage may be chronic or episodic, with binges ("s peed runs") punctuated by brief drug-free periods. Aggressive or violent behavior is associated w ith Amphetamine Dependence, especially when high doses are smoked, ingested, or administered intravenously. As w ith cocaine, intense
305.70
Amphetamine Abuse
225
but temporary anxiety resembling Panic Disorder or Generalized Anxiety Disorder, as well as paranoid ideation and psych otic episodes that resemble Schizophrenia, Paranoid Type, are often seen, especiaHy in association with hig h-dose use. Withdrawal states are often associated with temporary, but potentially intense, depressive symp toms that can resemb le a Major Depressive Epi sode. Tolerance to amphetamines d evelops and often leads to substantial escalation of the dose. Conversely, some individuals with Amphetamine Dependence develop sensitization, which is characterized by enhanced augmentation of an effect following rep ea ted exp osure. In these cases, small doses may produce marked stimulant and other adverse mental and neurological effects.
Specifiers
The following s pecifiers may be applied to a diagnOSiS of Amphetamine Dependence (see p. 195 for more details): With Physiological Dep enden ce Without Physiological Dependence Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission In a Controlled Environment
305.70
Amphetamine Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p. 198). Even individuals whose pattern of use d oes not meet cri teria for Dependence ca n d evelop multiple problems w ith these substances. Legal difficulties typically arise as a result of behavior while intoxicated with amphetamines (especially aggressive behavior), as a consequence of obtaining the drug on the illegal market, or as a result of drug possession or use. OccaSionally, individuals w ith Amphetanline Abuse w ill engage in illegal acts (e.g., manufacturing amphetamines, theft) to obtain the drug; h owever, this behavior is more common among those w ith Dependence. Individuals may con tinue to use the substance despite the knowled ge tha t continued use res uhs in arguments with famil y members while the individual is intoxica ted or presents a nega tive example to ch ildren o r other close famil y members. When these problems are accompanied by evidence o f tolerance, withdrawal, or compulsive behavior, a d iagnosis of Amphetamine Dependence rather than Abuse shou ld be considered . However, since some symptoms of tolerance, withdrawal, or compulsive use can occur in individuals with Abuse but not Dependence, it is important to determine whether the full criteria for Dependence are met.
226
Amphetamine-Induced Disorders
292.89 Amphetamine Intoxication
Refer, in addition, to the text and criteria for Substance Intoxication (see p. 199). The essential feature of Amphetamine Intoxica tion is the presence of clinically significant maladaptive behavioral or psych ological changes that develop during. or shortly after, lise of amphetamine or a related substance (Criteria A and B). Amphetamine lntoxication generally begins with a "high" feelin g, followed by the development of
symptoms such as euphoria with enhanced vigor, gregariousness, hyperactivity, restlessness, hypervigilance, interpersonal sensitivity. taJkativeness, anxiety, tension,
alertness, grandiosity, stereotyp ical and repetitive beha\' ior, anger, fighting , and impaired judgmen t. In the case of chronic intoxication, there may be affective blunting wi th fat igue or sadness and socia l w ithdrawal. These beh avioral an d psychological changes are accompanied by two or more of the following signs and symptoms: tachyca rdia or bradycardia; pupillary dilation; eleva ted or lowered blood pressure; pers piration or chills; nausea or vomiting; evidence of weight loss; psychomotor agitation or reta rdation; muscular weakness, res piratory depression, chest pain, or cardiac arrhy th mias; and confusion, seizures, d yskinesias, d ystonias, or coma (Criterion C). Amphetamine In tox ication, either acule or chron ic, is often associated with impaired social or occupational fun ctioning. The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Cri terion D). TIle magnitude and manifestations of the behavioral and physiological changes depend on the dose used and individual characteristics of the person using the substance (e.g., tolerance, rate of absorption, chronicity of use). The changes associated with intoxication begin usually within minutes (and sometimes within seconds) after substance use but may take lip to 1 hour, d epend ing on the sp ecific drug and method of delivery.
Specifi er
The following specifier may be applied 10 a diagnosis of Amphetamine Intoxication: With Percep tual Disturban ces. This sp ecifier may be n oted when hallucinations w ilh intact reali ty testing or auditory, visual, or tactile illusions occur in the absence of a delirium. IIlfaet reality testing mea ns that the person knows tha t the hallucinations are induced by the substance and do not represent external rea lity. When hallucinations occur in the absence of intact reality testing, a d iagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, shou ld be considered .
227
C. Two (or more) of the fo llowing, d eveloping during, o r sh o rt ly after, use of a mphetamine or a related substance:
(1) (2) (3) (4) (5) (6) (7) (8) (9)
tachycardia o r bradycard ia pupillary dilation elevated o r lowered blood pressure perspiration or chills nausea o r vo miting evidence of weight loss psychomotor agitatio n o r retardat ion muscular weakness, respiratory depression. chest pa in. or cardiac a rrhythmias confusion, seizures. d ysk inesias. dysto n ias. or coma
D. The symptoms are not due to a general med ical cond itio n and a re no t better a c-
292.0
Amphetamine Withdrawal
Refer, in addition, to the text and criteria fo r Substance Withdrawal (see p. 201 ). The essential feature of Amphetamine Withdrawal is the presence of a charac teristic withdrawal syndrome that d evelops w ithin a few hours to several d a}'s a fter cessation of (or reduction in) heavy and prolonged amphetamine use (Criteria A and 13). The ,Ose seen during in toxicasymp toms of wi thdrawal are, in general, the opposite of U tion. The withdrawal syndrome is characterized by the d evelopment of dysphoric mood and h\'o or more of the following physiolog ical changes: f.,tigue. v ivid and unpleasant dreams. insomnia or hypersomn ia. increased appetite, and psychomotor retardation or agitation. Anhedonia and drug craving can also be p resent but are not pacl of the diagnostic criteria . The symptoms cause cl inically significant distress or impairment in social, occupational. or other important areas of ftm cti on ing (Cri terion C). The symptoms must not be due to a genera l medical cond ition and are not better accounted for by another mental d isorder. Marked withdraw al symptoms ("crashing") often follow an episode of in tense, high-dose use (a "speed run "). Thls "crash" is characterized by intense and unpleasant feelings of lassitude and depression, generally requiring several d ays of rest and
C. The sym ptoms in Criterion B cause cl inically significant distress or impa irment in so-
cial, occupational, or other important areas of functio ning. D. The symptoms a re not due to a general medical condition a nd are not better accounted for by another mental disorder.
Amphetam ine-Related Oisorders Intoxication, paranoid ideation, audi tory hallucinations in a clear sensorium, and tactile hallucinations (e.g., fonnication or a feeling of bugs tmder the skin) may be experienced. Frequently, the person using the substance recognizes these symptoms as resulting from the stimulan ts. Extreme anger w ith threa ts o r acting ou t of aggreSSive beha vior may occur. Mood changes such as d epression with suicida l ideation, irritability, anhedonia, emotional lability, or d is turbances in attention and concentration are common, especially during withdrawal . Weight loss and other signs of malnutrition and impaired personal hygiene are often seen with sustained Amphetamine Dependence. Amphetamine-Related Disorders and other stimuJant-related d isorders are often "ssociated with Dependence on or Abuse of other substances, especiall)' those with sedative properties (such as alcohol or ben zod iazepines), which a re usually taken to reduce the tmpleasant, "j ittery" feelings that result from stimuJant drug effects. The laboratory and physical examination findings and the mental disorders and genera l medica l conditions that are associated with the Amphetamine-Related Disorders are generally simi lar to those that are associated with the Cocaine-Related Disorders (see p. 246). Urine tests for substances in this class usually remain positi ve for only 1- 3 days, even after a "b inge." Adverse pu lmonary effects are seen less often than with cocaine because substances in this cla ss are smoked fewer times per day. Seizures, H IV infection, malnutrition, gunshot or knife wounds, nosebleeds, and cardiovascular problems are often seen as presenting complaints in individuals with Amphetamine-Related Disorders. A hi story of ch ildhood Conduct Disorder and adult Antisocial Personality Di sord er may be associated with the later development of Amphetamine-Related Disorders.
Prevalence
The patterns of use of amphetamines in the general popu lation differ between locales (e.g., with high rates in southern California) and have nuctuated greatly over the years. In the Uni ted Sta tes, genera l use patterns were though t to peak in the early 1980s, when more than 25% of adults reported that they had ever used one of these drugs. Regarding more recent use, a 1996 na tional slln' ey of drug use reported that around 5% o f ad ults acknowledged ever having used "stimulant" drugs to get "high." ApprOximately 1% acknowledged having taken amphetamines in the prior year, and 0.4% acknowledged having taken amphetamines in the prior month. The peak p revalence of e\'er having used amphetamines was between ages 26 and 34 years (6%), while use in the last year was highest among 18- to 25-year-olds (2%). Some surveys have reported even higher patterns of use in some YOlmger cohorts.
1230
Substance-Related Disorders
A 1997 survey of high school seniors reported that 16% had ever used amphetaminelike drugs, including 10% in the prior year. It should be noted that because these surveys measured patterns of use rather than disorders, it is nol known how many of those in the surveys who used am phetamines had symptoms that met the criteria for Dependence or Abuse. Rates of Amphetamine Dependence and Abuse are m ore difficull to document. A national epidemiological study conducted in the United Sta tes in the early 19905 reported a 1.5% lifetime prevalence of these Amphetamine Use Disorders, including 0.14% in the past 12 months.
Course
Some individuals who develop Abuse or Dependence on amphetamines or amphetamine-like substances begin use in an attempt to control their weight. Others become introduced to these substances through the illegal market. Dependence can occur rapidly when the substance is used intravenously or smoked. O ral administration usually results in a slower progression from use to Dependence. Amphetamine Dependence is associated with tw o patlems of administration: episodic use or daily (or almost daily) use. In the episodic pattern, substance use is separated by d ays of nonuse (e.g., intense use over a weekend or on one or more weekdays).n,ese periods of intensive highdose use (often called "speed runs" or "binges") are often associa ted with intravenous use. RlUlS tend to terminate only when drug supplies are depleted . Chronic daily use may involve high or low doses and may occur throughout the day or be restricted to only a few hours. In chronic daily use, there are generally no wide fluctuations in dose on successive days, but there is often an increase in dose O\'er time. Chronic use of high doses often becomes unpleasant because of sensitization and the emergence of d ysphOriC and other nega tive drug effects. n,e few long-term data ava ilable indicate that there is a tend ency for persons who have been dependent on amphetamines to decrease or stop use after 8-10 years. "This appears to result from the development of ad verse mental and physical effects that emerge in association with long-term dependence. Little or no data are available on the long-term course of Abuse.
Differential Diagnosis
For a general d iscussion of the differen tial diagnosis of Substance-Related Disorders, see p. 207. Amphetamine-Induced Disorders may be characterized by symptoms (e.g., d elusions) tha t resemble primary men tal disorders (e.g., Schizophrenifonn Disorder or Schizophrenia versus Amphetamine-Induced Psychotic Disorder, With Delusions, With Onset During Intoxica tion). See p. 210 for a discussion of this differential diagnosis. Cocaine In toxication, H allucinogen Intoxication, and Phencycl id ine In toxication may cause a similar clinica l picture and can sometimes be distinguished from Amphetamine Intoxication only by the presence of amphetamine metabolites in a urine specimen or amphetamine in plasma . Amphetamine Dependence and Abuse should be distinguished from Cocaine, Phencyclidine, and Hallucinogen Dependence and Abuse. Amphetamine Intoxication and Amphetamine Withdrawal are d istinguished from the other Amphetamine-Ind uced Disorders (e.g., Amphetamine-Induced Anxiety Disorder, With Onset During Intoxication) because the symptoms in these latler
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231 \
disorders are in excess of those usually associated with Amphetamine In toxica tion or Amphetamine Withdrawal and are severe enough to warrant independent clinical attention.
292.9
The Amphetamine-Related Disorder Not Otherwise Specified ca tegory is for disorders associated with the use of amphetamine (or a related substance) that are not cla ssifiable as Amphetamine Dependence, Amphetamine Abuse, Amphetamine Intoxication, Amphetamine Withdrawal, Amphetamine Intoxication Delirium, Amphetam ine-Induced Psychotic Disorder, Amphetamine-Ind uced Mood Disorder, Amphetamine-Induced Anxiety Disorder, Amphetamine-Induced Sexual Dysfunction, or Amphetamine-Induced Sleep Disorder.
Caffeine-Related Disorders
Caffeine can be consumed from a number of different sources, including coffee (brewed = 100-140 mg/ 8 OZ, instant = 65-100 mg/ 80z), tea (40-100 mg/ 8 oz), caffeinaled soda (45 mg/ 12 oz), over-the-counter analgesics and cold remedies (25-50 mg/ tablet). antidrowsiness pill s (100--200 m g/ tablet), and weight-loss aids (75-200 mg/ tablet). Chocolate and cocoa have much lower levels of caffeine (e.g., 5 mg/ chocolate bar). The consumption of ca ffeine is ubiquitous in much of the United States, with an average caffeine intake of approximately 200 mg/ day, and up to 30% of Americans consuming SOO mg or more per day. Some individuals w ho drink large amounts of coffee display some aspects of dependence on caffeine and exhibit tolerance and perhaps withdrawaL H oweVer, the data are insufficient at tltis time to detennine whether these symptoms are associated with cl inically significant impairment that meets the criteria for Substance Dependence or Substance Abuse. in contrast, there is evidence that Caffeine Intoxication can be clinicall)' Significant, and specific text and criteria are provided below. Recent e\' idence also suggests the possible clinical relevance of caffeine w ithdrawal; a set of research criteria is included on p. 765. The Caffeineinduced Disorders (other than Caffeine Intoxication) are described in the sections of the manua l with disorders with which they share phenomenology (e.g., Caffeinelnduced Anxiety Disorder is included in the" Anxiety Disorders" section). Listed below are the Caffeine-Induced Disorders.
Caffeine-Induced Disorders
305.90 292.89 292.89 292.9
Caffeine Intoxication (see p. 232) Caffeine-Induced Anxiety Disorder (see p. 479) Specify if: With Onset During Intoxication Caffeine-lnduced Sleep Disorder (see p. 655) Specifij if: With Onset During lntoxication Caffeine-Related Disord er Not Othenvise Specified (see p. 234)
232
Caffeine-Induced Disorders
305.90
Caffeine Intoxication
Refer, in addi tion, to the text and criteria for Subs tance Intoxication (see p. 199). The essential feature of Caffeine Intoxication is recent consumption of caffeine and five or more symptoms that develop during, or shortly after, caffeine u se (Criteria A and B). Symptoms that ean appear foUowing the ingestion of as little as 100 m g o f caffeine per day include res tlessness, nervous ness, excitemen t, insomnia, flu shed face, diuresis,
and gastrointestinal complaints. Symptoms that genera lly appear at levels of more
than 1 g / d.1)' include muscle h dtching, rambling flow of thoughts and s peech, tachycardia or cardiac arrhythmia, periods o f inexhaustibi li ty, and psychomotor agita tion. Caffeine Lntoxication may not occur d espite high caffeine intake because of the de\'eJopmen t of tolerance. The SY J11ptoms must cause c1inicall)' significant distress or impairment in social, occupational, or ot her important a reas of functioni ng (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted fo r by another mental disorder (e.g., an Anxiety Disorder) (Criterion D).
of brewed coHee). B. Five (or more) of the followi ng signs, developi ng during, or shortly after, caffe ine use:
(1) restlessness
(2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
nervousness excitement insomnia flushed face diuresis gastroint estinal d isturbance muscle twitching rambling fl ow of t hought and speech tachycard ia or cardiac arrhythmia periods of inexhaustibility psychomotor agitation
C. The symptoms in Criterion B cause clinically significant d istress or impairment in social, occupationa l, or other import ant areas of fu nctioning.
O. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder (e .g., an Anxi ety Disorder).
233
Prevalence
The pattern of caffeine u se fluc tuates d u ring life, wi th 80%-85% of adults consuming caffeine in any given yea r. Among people w ho consume caffeine, 85% or more use a caffeine-containing beverage at least once a week, imbibing an average of almost 200 m g / day. Caffeine intake is probably elevated among individuals who smoke, and perhaps among those who use alcohol and other substances. The prevalence of Caffeine-Related Disorders is unknown.
234
Course
Caffeine intake us ually begins in the mid-teens, with increasing levels o f consumption through the 20s into the 305, w hen use levels off and perhaps begins to fall. Among the approximately 40% of individ uals w ho have stopped the intake of some form of caffeine. most report tilat they changed their pattern in response to its side effects or health concerns. The la ller incl ude cardiac arrhythmias, other heart problems. high blood p ress ure, fib rocystic di sease of the breast, insomnia, or anxiety. Becau se tolerance to the behaviora l effects of caffeine docs occur, Caffeine Intoxication is often seen in those who use caffeine less frequently or in those who have recently increased their caffeine intake by a subs tantial amOlmt.
Differentia l Diagnosis
For a general discussion of the differen tial diagnosis of Substance-Related Disorders, see p. 207. Caffeine-Induced Disorders may be characteri zed by symptoms (e.g., Panic Attacks) that resemble prim ary mental disorders (e.g., Panic Disorder versus Caffeine-Induced Anxiety Disorder, With Panic Attacks, '''' ith O nset During Intoxication). See p. 210 fo r a discussion of this differential diagnosis. To meet criteria for Ca ffeine Intoxication, the symptom s must not be due to a general med ical condition or an other mental disorder, su ch as an Anxiety Di sorder, that could better explain them. Manic Ep isodes, Panic Di sord er, General ized Anxiety Disorder, Amphetam ine Intoxicatio n, Sedative, Hy pnotic, or Anxiolytic Withdrawal or licotine Withdrawal, Sleep Disord ers, and medica tion-induced side effects (e.g., akathisia) can cause a clinical picture that is similar to that of Caffeine Intoxication. The temporal relations hip of the symptoms to increased caffeine u se or to abstinence from ca ffe ine helps to es tablish the diagnosis. Caffeine Intoxication is d ifferentiated from Caffeine-Induced Anxiety Disorder, With Onset During Intoxication (p. 479), and from Caffeine-Indu ced Sleep Disorder, With Onset During Intoxication (p . 655), by the fact tha t the symptoms in these latter disorders are in excess of those us ually associated with Caffeine Intoxication and are severe enough to warran t independent clinica l atten tion.
Cannabis-Related Disorders
This section includes problems that are associated with substances that are derived from the c.lIlnabis plant (c.lIlnabinoids) and chemically similar synthetic compOlmds.
Cannabis-Related Disorders
When the upper leaves, tops, and stems of the plant are cut, dried, and rolled into cigarettes, the product is usually called marijuana o r bhang. Hashish is the dried, resinous exudate that seeps from the tops and undersides of cannabis leaves; h ashish oil is a concentrated distillate of hashish. In recent years, another high-potency form of c.mnabis, sensimilla, has been produced in Asia, H awaii, and California. Cannabinoids are usually smoked, but they may be taken o rally, usually m ixed with tea or food. The cannabinoid tha t has been identified as primarily responsible for the psychoacti ve effects of cannabis is delta-9-tetrahydrocannabinol (also known as THC, or delta-9-THC), a substance that is rarely ava ilable in a pure form. The carm abinoids have d iverse effects in the brain, prominent among which are actions on CBI and CB2 cannabinoid receptors that arc found throughout the central nervous system. Endogenous ligands for these receptors, anandamide and N-palmitoethanoiamide, behave essen tially like neurotransmitters. The THC content of the marijuana that is generally available varies grea tly. The THe con tent of illicit marijuana has increased signific.m tl), since the late 1960s from an average of approximately 1%-5% to as much as 10"10-15"10. Synthetic d elta-9-THC has been used for certain general medical conditions (e.g., for nausea and vomiting caused by chemotherapy, for anorexia and weight loss in individ uals with acquired immunodeficiency syndrome IAIDS)). TIlis section con tains d iscussions sp ecific 10 the Cannabis-Related Disorders. Texts and criteria sets have already been provided 10 define the gen eric aspects of Substance Dependence (p. 192) and Substance Abu se (p. 198) that apply across all substances. The applica tion of these general criteria to Cannabis Dependence and Abuse is prov ided below . However, there are no unique cri teria sets for Cannabis Dependence or Cannabis Abuse. A sp ecifiC text and criteria set for Cannabis In toxication is also prov ided below. Symptoms of p ossible cannabis withdrawal (e.g., irritable or anxious mood accompanied by physiological changes such as tremor, perspiration, na usea, change in appetite, and sleep disturbances) have been described in association with the use of vcry high doses, but their clinical sign ifican ce is uncertain. For these reasons, the diagnosis of cannabis withdrawal is nol included in this manual The Cannabis-Induced Disorders (other than Cannabis Intoxication) are described in the sections of the manua l with disorders with which they share phenomenology (e.g., Cannabis-Induced Mood Disorder is included in the "Mood Disorders" section). Listed below are the Cannabis Use Disorders and the Cannabis-Ind uced Disorders.
236
292_ 11 292.89 292.9
Substance-Related Disorders Cannabislnduced Psychotic Disorder, With Hallucinations (see p. 338) Specify if: With Onset During Intoxication Cannabis-Induced Anxiety D isorder (see p. 479) Specify if: With Onset During Intoxication Cannabis-Related Disorder Not Othen... ise Specified (sec p. 241)
Refer, in addi tion, to the text and criteria for Substance Dependence (see p. 192). Individua ls wi th Cannabis Dependence have compulsive use and associated problems. To lerance to most of the effects of ca nnabis has been reported in individuals who use ca nnabis chronically. There have also been some reports of withdrawal symptoms, but their clinica l significance is uncertain. There is some evidence that a majority of chronic lIsers of cannabinoid s report histories of tolerance or withdrawal and that these individuals evidence more severe drug-rela ted problems overall. Individuals with Cannabis Dependence may lise very potent cannabis throughout the day over a period of m onths or yeaTS, and they may spend several hours a day acquiring and using the substance. This often interferes with fami ly, school, work, or recrea tiona l activities. Individuals with Cannabis Dependence may a lso persist in their use despite knowledge of physical problems (e.g., chronic cough related to smoking) or psychologica l problems (e.g., excessive sedation and a decrease in goal-oriented activities resulting from repeated use of high doses).
Specifiers
The following specifiers may be applied to a diagnOSiS o f Cannabis Dependence (see p. 195 for more detai ls): \Vith Physiological Dependence Without Physiological Depe ndence Early Full Remission Early Partial Remi ssion Sustained Full Remission Sustained Partial Remission In a Controlled Environment
305.20
Cannabis Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p. 198). Periodic cannabis use and intoxication can in terfere with performance at work or school and may be physically h azardous in sihlations such as driv ing a car. Legal problems may occur as a consequence of arrests for cannabis possession. There may be arguments with spOllses or parents over the possession of cannabis in the home or its use i.n the presence of children. \,\' hen psychological or physica l problems are associated with
292.89
237 1
ca nnabis in the context of compulsive use, a diagnosis of Cannabis Dependence, rather than Cannabis Abu se, should be considered .
Cannabis-Induced Disorders
Specifier
The follow ing specifier may be applied to a diagnosis of Cannabis In toxication: With Perceptual Disturban ces. This specifier may be noted when hallucinations w ith in tact reality testin g o r auditory, visual, or tactile illusions occw in the absence of a delirium. Illtact reality testing means that the person knows that the halluci nations are induced by the substance and do not represent external reality. \ h en hallucina tions occur in the absence o f intact re.l lity testing, a diagnosis o f Substance-Induced Psychotic Disorder, Wi th Hallucina tions, should be considered.
238
e.
Two (or more) of the following signs, developing within 2 hours of cannabis use:
(1) conjunctival injection
(4) tachycardia
D. The symptoms are not due to a general medical condition and are n ot better accounted for by another menta l disorder.
Specify if:
Cannabis-Related Disorders
(e.g., concern that the police will discover the substance use) to severe anxiety reactions resembling Panic Attacks. There may also be paranoid ideation ranging from suspiciousness to frank delusions and hallucinations. Episodes of d epersonalization and derealization have also been reported. Fatal traffic accidents have been found to occur more o ften in individuals who test positive forcannabinoids than in the general population. H owever, the significance of these findings is unclear because alcohol and other substances are often also present. Associate d laboratory findings. Urine tests generally identify cannabinoid metabolites. Because these substances are fat soluble, persist in bodily fluid s for extended periods of time, and are excreted slowly, routine urine tests for cannabinoids in individuals who use cannabis casually can be positive for 7-10 days; urine of individuals with heavy use of cannabis may test positive for 2-4 weeks. A p ositive urine test is only consistent with past use; it does not establish Intoxica tion, Dependence, or Abuse. Biological alterations include temporary (and probably d ose-related ) suppression of immunological function and suppressed secretion of testosterone and luteinizin g hormone (LH), although the clinical Significance o f these alterations is unclear. Acute cannabinoid use also causes d iffuse slowing of background activity on EEG and rapid eye movement (REM) supp ression. Associat e d physica l examination find ings and general medical conditions. Cannabis smoke is highJy irritating to the nasopharynx and bronchial lining and thus increases the risk for chronic cough and other signs and symptoms of nasopharyngeal patho logy. Chronic cannabis use is sometimes associated with weight gain, probably resulting from overeating and reduced physical activity. Sinusitis, pharyngi tis, bronchitis with persistent cough, emphysema, and pulmonary dysplasia may occur with chronic, heavy use. Marijuana smoke contains even larger amounts of known carcinogens than tobacco.
Preva lence
Cannabinoids, especia lly cannabis, are also the most widely llsed illicit psychoactive substances in the United States. Although the lifetime prevalence figures slowly decreased in the 1980s, modest increases were reported between 1991 and 1997, especially among youth. A 1996 national survey of drug use noted that 32% o f the US. popu lation reported ever having used a cannabinoid . Almost 1 in 11 had used it in the prior year, and around 5% had used it in the past month. The age span with the highest lifetime prevalence was 26 to 34 yea rs (50%), but use in the last year (24%) and
Course
Cannabis Dependence and Abuse usually develop over an extended period of time, although the progression might be more rapid in young people w ith pervasive conduct p roblems. Most people who become depend ent typically establish a pattern of chronic use that gradually increases in both frequency and amount. With chronic heavy use, there is sometimes a diminution or loss of the pleasu rable effec ts of the substance. Although there may also be a corresponding increase in d ysphOric effects, these are not seen as freq uently as in chronic use of other substances such as alcohol, cocaine, or amphetamines. A history of Conduct Disorde r in childhood o r adolescence and Antisocial Personality Disorder are risk fa ctors for the d evelopment of many Substance-Related Disorders, induding CaImabis-Related Disorders. Few data are available on the long-term cou rse of Cannabis Dependence or Abuse. As w ith alcohol, caffeine, and nicotine, cannabinoid use ap pea rs early in the course of substance use in man}' people who later go on to develop Dependence on other substances-an observation that has led to speculation tha t cannabis might be a "gateway drug." However, the social, psychological, and neurochemica l bases of this possible progression are not well understood, and it is not d ear that marijuana actually causes individuals to go on to use addi tional types of substances.
Differential Diagnosis
For a general discussion of the d iffe ren tial d iagnosis o f Substance-Related Disorders, see p. 207. Cannabis-Induced Disorders may be characterized by sympto ms (e.g., anxiety) that resemble primary mental disorders (e.g., Generalized Anxiety Disorder versus Cannabis-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Intoxication). See p. 210 for a discussion of this d ifferential diagnosis. Chronic intake of cannabis can produce a lack of motivation that resembles Dysthymic Disorder. Acute ad verse reactions to cannabis should be differentiated fro m the symptoms of Panic Disorder, Major Depressive Diso rder, Delusional Disorder, Bipolar Disorder, or Schizophrenia, Paranoid Type_ Physical examination w HI usually show an increased pulse and injected conjunctivas. Urine toxicological testing can be helpful in making a d iagnosis. In contrast to Cannabis Intoxication, Alcohollntoxication and Sedative, Hypnotic, or Anxiolytic Intoxication frequentl y d ecrease appetite, increase aggressive behavior, and produce nystagmus or ataxia . Hallucinogens in low doses may cause a clinic.11 picture that resembles Cannabis Intoxication . PCP, like cannabis, ca n be smoked and
241
also causes perceptual changes, but Phencyclidine Intoxica tion is much more likely to cause ataxia and aggressive behavior. Cannabis Intoxication is distinguished from the other Cannabis-Induced Disorders (e.g., Cannabis-Induced Anxiety Di sorder, With Onset During Intoxication) because the symptoms in these latter disorders are in excess of those usually associated with Cannabis Intoxication and are severe enough to warrant independent clinical attention. The distinction beh\'een occasional use of cannabis and Cannabis Dependence or Abuse can be difficult to make beca use social, behavioral, or psychological problems may be difficult to attribute to the substance, especially in the context of use of other substances. Denial of heavy use is common, and people appear to seek treatment for Cannabis Dependence or Abuse less often than for o ther ty pes o f Substance-Related Disorders.
Cocaine-Related Disorders
Cocaine, a naturally occurring substance produced by the coca plant, is consumed in several preparations (e.g., coca leaves, coca paste, cocaine hydrochloride, and cocaine alkaloids such as freebase and crack) that d iffer in potency due to varying levels of purity and speed of onset. However, in all fonns, cocaine is the acti ve ingredient. Chewing coca leaves is a practice generally limited to nati ve populations in Centra l and South America, w here cocaine is grown. The use of coca paste, a crude extract of the coca plant, occurs almost exclusively in cocaine-producing countries in Central and South Am erica, where its nick.name is "basulca." Solven ts used in the preparation of coca paste often contaminate the paste and may cause toxic effects in the central nervous system and other organ systems w hen the paste is smoked . Cocaine hydrochloride powder is usually "snorted " through the nostrils ("snorting") or d issolved in water and injected intravenously. It is sometimes mixed with heroin, yielding a drug combination known as a "speedball." A commonly used form of cocaine in the United States is "crack," a cocaine alkaloid that is extracted from its powdered hydrochloride salt by mixing it with sodium bicarbonate and allowing it to dry into small "rocks." Crack differs from other forms of cocaine primarily because it is ea sily vaporized and inhaled and thus its effec ts have an extremely rapid onset. The clinical syndrome and adverse effects that are associated with crack lise are identical to those produced by comparable doses of other cocaine preparations. Before the advent of crack, cocaine was separated from its hydrochloride base by heating it with ether, ammonia, or some other volatile solvent.
242
Su bstance-Related Disorders
The resul ting "free base" cocaine was then smoked. This process was dangerous because of the risk that the solvents could ignite and harm the user.
This section contains discussions specific to the Cocaine-Rela ted Disorders. Texts
and criteria sets have already been provided to define the generic aspects of Substance Dependence (p. 192) and Substance Abuse (p. 198) th at apply across all substances. The application of these general criteria to Cocaine Dependence and Abuse is provided below . However, there are no unique criteria sets for Cocaine Dependence or Cocaine Abuse. Specific texts and criteria sets for Cocaine Intoxication and Cocaine Withdrawal a re also provided below. The Cocaine-Induced Disorders (other than Cocaine Intoxication and Withdrawal) are described in the sections of the manual w ith disorders with which they share phenomenology (e.g., Cocaine-Induced Mood Disorder is included in the "Mood Disorders" section). Lis ted below are the Cocaine Use Disorders and the Cocaine-Induced Disorders.
Cocaine-Induced Disorders
292.89 292.0 292.81 292.11 292.12 292.84 292.89 292.89 292.89 292.9 Cocaine Intoxication (see p. 244) Specify if: With Percephtal Dis turbances Cocaine Withdrawal (see p . 245) Cocaine In toxication Delirium (see p. 143) Cocaine-Induced Psychoti c Disorder, With Delusions (see p. 338) Specify if: With Onset During intoxication Cocaine-Induced Psychotic Disorder, With Hallucinations (see p . 338) Specify if: With Onset OUTing intoxication Coca ine-Induced Mood Disorder (see p. 405) Specify if: With Onset DuTing Intoxication / W ith Onset During Withdrawal Cocaine-Induced Anxiety Disorder (see p. 479) Specify if: With Onset During Lntoxication / With Onset During Withdrawal Cocaine-Induced Sexual D ysfuncti on (see p. 562) Specify if: With Onset During lntoxication Cocaine-Induced Sleep Diso rder (see p. 655) 5pecifiJ if: With Onset During Intoxication/ With Onset During Withdrawal Cocaine-Related Disorder Not Othenvise Specified (see p. 250)
Refer, in addition, to the text and criteria for Substance Dependence (see p . 192). Cocaine has extremely potent euphoric effects, and indiv iduals exposed to it can develop Dependence after using the drug for very short periods of time. An early sign of
305.60
Cocaine Abuse
243 1
Cocain e Dependence is when the individual find s it increasingly difficult to resist us~ ing cocaine whenever it is available. Because of its short half-life of about 30-50 minutes, there is a need for frequent dosing to maintain a "high ." Persons with Cocaine Dependence can spend extremely large amounts of m oney on the drug within a very short period of time. As a result, the person using the substance may become involved in theft, prostitution, or drug dealing or may requ est salary ad vances to obtain funds to purchase the drug. Individuals with Cocaine Dependence often find it necessary to d iscontinue use for several days to rest or to obtain additional fund s. Important responsibilities sllch as work or child care may be grossly neglected to obtain or use cocaine. Mental or physical complications of dliOruC use su ch as paranoid ideation, aggressive behavior, anxiety, depression, and weight loss are common. Regardless of the route of administration, tolerance occurs with repeated lise. Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoric mood, can be seen and are likely to enhance craving and the likelihood of relapse. The overwhelming majority of individuals with Cocaine Dependence have had signs of physiologica l dependence on cocaine (tolerance or withdrawal) at some time during the COLUse of their substance use. The designation of "Wi th Physiological Dependence" is associated with an earlier onset of Dependence and more cocaine-related problems.
Specifiers
The following specifiers may be applied to a diagnosis o f Cocaine Dependence (see p. 195 for more details): With Physiologi cal Depend ence Without Phys iolog ical Dependence Early Full Remi ssion Early Partial Remission Sustained Full Remission Sustained Parti al Remission In a Controlled Environment
305.60
Cocaine Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p. 198). The intensity and frequency of cocaine administra tion is less in Cocaine Abuse as compared with Dependence. Episodes of problematic use, neglect of responsibiUties, and interpersonal conflict often occur around paydays or s pecial occasions, res ulting in a pattern of brief periods (hours to a few days) of high-dose use followed by much longer period s (weeks to months) of occasional, nonproblematic use or abstinence. Legal difficulti es may result from possession or u se of the drug. When the problems associated with use are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to obtaining and administering cocaine, a d iagnosis of Cocaine Dependence ra ther than Cocaine Abuse should be considered. However, since some symptoms of tolerance, withdrawal. or compulsive use can occur in individuals w ith Abuse but not Dependence, it is important to determine whether the full criteria for Dependence are met.
Substance-Related Disorders
Cocaine-Induced Disorders
292.89 Cocaine Intoxication
Refer, in addition, to the text and cri teria for Substance Intoxication (see p. 199). The essential feature of Cocaine Intoxication is the presence of clinically significant maladaptive behavioral or psycholOgica l changes that develop during, or shortly after, use of cocaine (Criteria A and 6). Cocaine Intoxication usually begins with a "high" fee ling and includes one or more of the following: euphoria with enhanced vigor, gregariousness, hyperactiv ity, restlessness, hypervigilance, interpersonal sensitivity, talkativeness, anxiety, tension, alertness, grandiosity, stereotyped and repetitive behavior, anger, and impaired judgment, and in the case of chronic intoxication, affecti ve blunting with fatigue or sadness and socia l withdrawal. These behavioral and psychological changes arc accompanied by hvo or more of the following signs an d symptoms that develop during or shortly after cocaine use: tachycardia or bradycardia; pupillary dilation; elevated or lowered blood pressure; perspiration or chills; nausea or vomiting; evidence of weight loss; psychomotor agita tion or retardation; muscular weakness, respira tory depression, chest pain, or cardiac arrhythmias; and confusion, seizures, d yskinesias, dystonias, or coma (Criterion C). Intoxication, either acute o r chronic, is often associated with impaired social or occupational functioning . Severe intoxication can lead to convulsions, cardiac arrhythmias, hyperpyrexia, and death. To make a diagnosis of Cocaine Intoxication, the symptoms must not be due loa general medical condition and are not better accounted for b y another mental disorder (Criterion D). TIle magnitude and direction of the behavioral and physiological changes d epend on many variables, including the dose used and the individual characteristics of the person using the substance (e.g., tolerance, rate of absorption, chronicity of use, context in which it is taken). Stimulant effects such as euphoria, increased pulse and blood pressure, and psychomotor activity are most commonly seen. Depressant effects such as sadness, bradycard ia, decreased blood pressure, and decreased psychomotor activity are less common and generally emerge on ly w ith chronic high-dose use.
Specifier
The following specifier may be applied to a diagnosis of Cocaine Intoxication: With Perceptual Disturbances. This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. llltnct renlity testillg means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Ind uced PsydlOtic Disorder, With Hallucinations, should be considered.
292 .0
Cocaine Withdrawal
or affective blunting; changes in sociability; hypervigilance; inte rpersona l sensitivity; anxiety, tension, or anger; stereotyped behaviors; impa ired judgment; or impaired social or occupational functioning) that developed during. or shortly after, use of cocaine.
C. Two (or more) of the following. developing during, or shortly after, cocaine use:
(1) (2) (3) (4) (5) (6) (7) (8) (9)
tachyca rdia o r bra dycardia pu pillary dilation elevated or lowered blood pressure perspiration or chills nausea or vomiting evidence of weight loss psychomotor ag itation o r retardati o n muscular weakness, respiratory depression, chest pain. or cardiac arrhythmias confusion, seizures, dyskinesias, dystonias, or coma
D. The symptoms are not due to a general medical condition and are not better ac-
292.0
Cocaine Withdrawal
Refer, in additio n, to the text and criteria fo r Substance Withdrawal (see p. 201). The essential feature of Cocaine Withdrawal is the presence of a characteris tic w ithdrawal syndrome that develops wi thin a few hours after the cessation of (or reduction in) cocaine use that has been heavy and prolonged (Criteria A and B). The w ithdrawal syndrome is characterized by the development o f d ysphoriC mood accompanied by h vo or m ore of the following physiological changes: fatig ue, vivid and unpleasant dreams, insomnia or h yp ersomnia, increased appetite, and psychomotor retardation or agitation. Anhedonia and drug craving can often be present but are not part of the diagnostic criteria . These symptoms cause clinically significant dis tress or impairment in social, occupational, or other important areas of hmctioning (Criterion C). The symptoms mus t not be due to a general medical condition and are not better accounted for by another mental disorder (Crite rion D). Acute withdrawal symptoms ("a crash") are ofte n seen after period s of repetitive high-dose use ("runs" or "binges"). These p eriod s are cha racterized by intense and unpleasant feelings of lassitude and depression and increased a p petite, generally requiring several days of rest and recuperation . Depressive symptoms w ith suicidal ideation or behavior can occur and are generally the most serious problems seen during "crashing" or other forms of Cocaine Withdrawal.
Substance-Related Disorders
B. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:
(1) fatigue
vivid, unpleasant dreams insomnia or hypersomnia increased appetite psychomotor retardation or agitation
C. The symptoms in Criterion B cause clin ically significant distress or impairment in so-
cial, occupational, or other important areas of functioning. D. The symptoms are not du e to a general medical condition and are not better accounted for by another mental disorder.
247
Aggressive behavior can result from the effects of cocaine; violence is also associated with the cocaine "trade." Promiscuous sexual behavior either as a result of increased desire or using sex fo r the purpose of obtaining cocaine (or fo r money to purchase cocaine) has become a factor in the spread of sexually transmitted diseases, including human immunodeficiency virus (HIV). Acute Intoxication with high doses of cocaine may be associated with rambling speech, headache, transient ideas of reference, and tinnitus. There may also be paranoid ideation, auditory hallucinations in a clear sensorium, and tactile hallucinations ("coke bugs"), which the user usually recognizes as effects of cocaine. Extreme anger with threats or acting out of aggressive behavior may occur. Mood changes s uch as depression, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in attention and concentration are common, especially during Cocaine Withdrawal. Indiv iduals with Cocaine Dependence often have temporary depressive symptoms that meet symptomatic and duration criteria for Major Depressive Disorder (see Substance-Induced Mood Disorder, p. 405). Histories consistent w ith repeated Panic Attacks, social phobic-like behavior, and generalized anxiety-like syndromes are not uncommon (see Substance-Induced Anxiety Disorder, p. 479). Eating Disorders may also be associated with this subs tance. One of the most extreme instances of cocaine toxicity is Cocaine-Induced Psychotic Disorder (see p. 338), a disorder with delusions and hallu cinations that resembles Schizophrenia, Paranoid Type. Menta l d isturbances that occur in association WiUl cocaine use usu ally resolve within hours to days after cessation of use, although they can persist for as long as a month . Individuals with Cocaine Dependence often develop conditioned responses to cocaine-related stimuli (e.g., craving on seeing any white powder-like substance)a phenomenon that occurs with most drugs that cause intense psychological changes. These responses probably contribute to relapse, are difficult to extinguish, and typically persist long after detoxification is completed. Cocaine Use Disorders are often associated with other Substance Dependence or Abuse, especially involving alcohol, marijuana, heroin (a speedball), and benzodiazepines, w hich are often taken to reduce the anxiety and other unpleasant s timu lant side effec ts of cocaine. Cocaine Dependence may be associated with Posttraumatic Stress Disorder, Antisocial Personality Disorder, Attention-Deficit / Hyperactivity Disorder, and Pathological Gambling. Assodated laboratory findings. Most laboratories test for benzoylecgonine, a metaboli te of cocaine that typically remains in the urine fo r 1-3 days after a single dose and may be present for 7-12 days in those using repeated high doses. Mildly elevated liver function tests can be seen in individuals who inject cocaine or use alcohol excessively in association w ith cocaine. Hepatitis, sexually transmitted d iseases including HIV, and tuberculosis may be associated with cocaine use. Pneumonitis or pneumothorax are occasionally observed on chest X ray. Discontinuation of chrome cocaine use is often associated with EEG changes, alterations in secretion patterns of prolactin, and down-regulation of dopamine receptors. Associated physical examination findings and general medical conditions. A wide range of general medical conditions may occur that are specific to the route of
248
Substance-Related Disorders
administration of cocaine. Persons who use cocaine intranasally ("snort") often develop sinusitis, irritation and bleeding of the nasal mucosa, and a perforated nasal
septum . Those who s moke cocaine are at increased risk for respiratory problems (e.g., coughing, bronchitis, and pneumonitis due to irritation and inflammation of the tiss ues lining the res pirato ry tract). Persons w ho inject cocaine have puncture marks and "tracks," m ost common ly on their forearms, as Seen in those w ith Opioid Dependence. HIV infection is associated with Cocaine Dependence due to the frequent intravenous injections and the increase in promiscuous sexua l behavior. Other sexually trans m itted diseases, hepatitis, and tuberculosis and o ther lung infections are also seen . Cocaine Dependence (with any route of administration) is commonly associated with s igns of weight loss and malnutrition because of its appetite-suppressing effects. Ches t pain may also be a common symptom. Pneumothorax can result from performing Valsa lva-like mane uvers that are done to better absorb coca ine thai has been inhaled. Myocardial infarc tion, palpita tions and arrhythmias, sudden d eath from res pira tory or cardiac a rrest, and s troke have been associated with cocaine use among you ng and otherwise hea lthy persons. TIlese incidents are probably ca used by the abili ty of cocaine to increase blood pressure, cause vasoconstriction, or alter the electrical activity of the heart. Seizures have been obsen'ed in association with cocaine use. Traumatic injuries due to dis putes resuJting in v iolent behavior are common, especially among persons w ho sell cocaine. Among pregnant females, cocaine use is associated with irregula rities in placental blood flow, abruptio placentae, premahu e labor and delivery, and an increased prevalence of in fants with very low birth weights.
Prevalence
As with most drugs, the prevalence of cocaine use in the United States has fluctuated greatly over the years. After a peak in the 19705, the proportion of the population who have used cocaine in any of its fo rms gradually decreased unli l the early 1990s, after which the pace of diminution con tinued but at a slower ra te of decline. A 1996 national s un'ey of drug use reported that 10% of the population had ever used cocaine, with 2% reporting use in the last year and 0.8% reporting use in the last month. Crack use was much less p revalent, w ith around 2% of the populal'ion re porting lifetime use, 0.6% re portin g u se in the prior year, and 0.3% reporting use in the prior month. individuals between ages 26 and 34 years reported the highest rates of lifetime use (21% for cocaine and 4% for crack). Ho wever, the age group with the h ighest ra te over the pas t year (5% for cocaine and 1% for crack) was 18- to 25-year-o ld s. It should be noted
Cocaine-Related Disorders
249
that because these SlITVeys measured patterns of use rather than disorders, it is not known how many of those in the slln'ey who used cocaine had symptoms that met the criteria for Dependence or Abuse. The lifetime rate of Cocaine Abuse or Dependence was reported to be almost 2% in a 1992 community slln'ey conducted in the United Slates, w ith a prevalence in the prior 12 months of about 0.2%.
Course
As with amphetamines, Cocaine Dependence is associated with a variety of pattems of seU-administration, including episodic or daily (or almost daily) use. In the episodic pattem, the cocaine use tends to be separated by 2 or more days of nonuse (e.g., intense use over a weekend or on one or more weekdays). " Binges" are a form of episodic use that typically involve continuolls high-dose use over a period of hours or days and are often associated with Dependence. Binges usually terminate only when cocaine supplies are depleted. Chronic daily use may involve high or low doses and may occur throughout the day or be restricted to only a few hours. In chronic dai ly use, there are generally no wide fluctuation s in dose on su ccessive days, but there is often an increase in dose over time. Cocaine smoking and intravenous use tend to be particularly associated with a rapid progression from use to abuse or dependence, often occurring over weeks to months. Intranasal use is associated with a more gradual progression, usually occurring over months to years. Dependence is commonly associated with a progressive tolerance to the desirable effects of cocaine leading to increasing doses. With continuing use, there is a diminution of pleasurable effects due to tolerance and an increase in dysphoric effects. Few data are available on the long-term course of Cocaine Use Disorders.
Differential Diagnosis
For a genera 1discussion of the differentia 1diagnosis of Substance-Rela ted Disorders, see p. 207. Cocaine-Induced Disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders (e.g., Major Depressive Disorder versus Cocaine-Induced Mood Disorder, With Depressive Feahtres, With Onset During Withdrawal) . See p. 210 for a discussion of this differential diagnosis. The marked mental dis turbances that can result from the effects of cocaine should be distinguished from the symptoms of Schizophrenia, Paranoid Ty pe, Bipolar and other Mood Disorders, Generalized Anxiety Disorder, and Panic Disorder. Amphetamine Intoxication and Phencyclidine Intoxication may cause a similar clinical picture and can often only be distinguished from Cocaine Intoxication by the presence of cocaine metabolites in a urine specimen or cocaine in plasma. Cocaine Intoxication and Cocaine Withdrawal are distinguished from the other CocaineInduced Disorders (e.g., Cocaine-Induced Anxiety Disorder, With Onset During Intoxication) because the symptoms in these latter disorders are in excess of those usually associated with Cocaine Intoxication or Cocaine \<\Iithdrawal and are severe enough to warrant independent clinical attention.
250
Substance-Related Disorders
Hallucinogen-Related Disorders
This diverse group of substances includes ergot and related compounds (lysergic acid diethylamide (LSD1, morning g lory seed s), phenylalkylamines (mesca line, "STP"
[2,5-dimethoxy-4-methylamphetaminel, and MDMA 13,4-methylenedioxymethamphetaminei also caUed " Ecstasy" ]), indole alkaloids (psilocybin, DMT [dimethyltryptamine]), and miscellaneous other compounds. Excluded from this group are phencyclidine (PCP) (p. 278) and cannabis and its active compound, deJta-9-tetrahydrocannabinol (THC) (p. 234). Although these substances can have hallucinogenic effects, they are discussed separately because of significant differences in their other psychological and behaviora l effects. Hallucinogens are usually taken orally, although DMT is s moked, and use by injection does occur. This section contains discussions specific to the Hallucinogen-Related Disorders. Texts and criteria sets have already been provided to define the generic aspects of Substance Dependence (p . 192) and Substance Abuse (p. 198) that apply across all substances. Theapplication of these general criteria to H allucinogen Dependence and Abuse is provided below. However, there are no unique criteria sets for Hallucinogen Dependence or Hallucinogen Abuse. A specific text and criteria set for Hallucinogen Intoxica tion is also provided below. Tolerance develops with repeated use, but a clinically significant withdrawal from these subs tances has not been well documented. For this reason, the diagnosis of hallucinogen w ithdrawal is not included in this manuaL llle Ha llucinogen-Induced Disorders (other than Hallucinogen Intoxication) are described in the sections of the manual with disorders with which they share phenomenology (e.g., Hallucinogen-Induced Mood Disorder is included in the "Mood Disorders" section). Listed below are the Hallucinogen Use Disorders and the H,l11ucinogen-Induced Disorders.
304.50
251
Hallucinogen-Induced Disorders
292.89 292.89 292.81 292.11 292.12 292.84 292.89 292.9 Hallucinogen Intoxication (see p. 252) Hallucinogen Persisting Perception Disorder (Flas hbacks) (see p. 253) Hallucinogen lntoxica tion D elirium (see p . 143) Hallucin ogen-Indu ced Psych otic Disorde r, With Delusions (see p. 338) Specify if: With Onset During Intoxication Halluci n oge n-Induced Psychoti c Di sorder, With Hall uci nations (see p. 338) Specify if: With Onset During Intoxication Hallucinogen-lnduced Mo od Disorder (see p. 405) Specify if: With Onset During Intoxication H allucinogen-Induced Anxiety Disorder (see p . 479) Specify if: With Onset During Intoxication H allucinogen-Related Disord er Not Oth en vise Sp ecifi ed (see p . 256)
Refer, in addition, to the text and criteria for Substance Dependence (see p. 192). One of the generic Dependence criteria (i.e., w ithdrawal) does not apply to hallucinogens, and others require further explanation. Tolerance has been reported to develop rapidly to the euphoric and psychedelic effects of hallucinogens but not to the autonomic effects such as p upillary dilation, hyperreflexia, increased blood pressure, increased body tempera ture, piloerection, and tachycardia . Cross-tolerance exists between LSD and other hallucinogens (e .g., psilocybin and mescaline) but d oes not extend to most other ca tegories of drugs such as PCP and cannabis. Hallucinogen u se, even among individuals with presentations that meet full criteria for Dependence, is often limited to only a few times a week. Although withdrawal has been shown only in animals, dear reports of "a,wing" after s topping hallucinogens are known . Because of the long half-life and extended dtuation of action of most hallucinogens, individuals with Hallucinogen Dependence often spend hours to days using and recovering from theireffecls. ln contrast, some hallucinogenic drugs (e.g ., DMT) are quite short acting. Hallucinogens may continue to be u sed despite the knowledge of ad verse effects (e.g ., memory impainnent while intoxicated; "bad trips." which are usually panic reactions; or fl ashbacks) . Some individua ls wh o u se MDMA (an amphetamine-like drug with hallucinogenic effects) describe a "hangover" the day after use that is ch aracterized by insomnia, fatigue, drowsiness, sore jaw muscles from teeth cienciling, toss of balance, and h eadaches. Because adulterants or substitutes are often sold as "acid" or other hallucinogens, some of the reported adverse effects may be due to substances such as strycimine, PCP, or amphetamine. Some individuals can manifest dangerous behavioral reactions (e.g., jumping out of a window under the belief that one can "fly ") due to lack of insight and judgmen t w hile intoxicated. These adverse effects appear to be more common among those w ho have preexisting mental disorders.
252
Specifiers
The follOWing specifiers may be applied to a diagnosis of Hallucinogen Dependence (see p. 195 for more details) :
Early Full Remission Early Partial Remission Sus tained Full Remission Sus tained Partial R em iss ion In a Controlled En vironme nt
30 5.30
Hallucinogen Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p . 198) . Pers ons who misuse hallucinogens are likely to use them much less often than d o those with Depen dence. However, they may repeatedly fail to fulfill major role obligations at school, work, or home due to beh avioral impairmen t caused by H allucinogen lnlox icatian. The individual may u se hallucinogens in s ituations in which it is physically hazardous (e.g., while d riving a motorcycle or a car), and legal difficulties may arise due to behaviors that result from intoxication or p ossession of hall ucinogens. There may be recurren t social or interpersonal problems due to the individual's behavior while intoxicated, isolated Westyle, or arguments with significant others.
Refer, in addition, to the text and cri teria for Substance In toxication (see p . 199) . The essential feature of Hallucinogen Intoxication is the presence of clinically significant maladaptive behavioral or psychological ch anges (e.g., marked anxiety or depression, ideas of reference, difficulty focusing attention, fear of losing one's mind, paranoid ideation, impaired judgment, or impaired social or occupational functioning) that develop during or shortly after (within minutes to a few hours of) hall ucinogen use (Cri teria A and B). Perceptual changes are a central part of in toxication, d eveloping during or shortly after hallucinogen use and occur in a state of full wakefulness and alertness (Criterion C). These changes include subjective intensification of perceptions, depersonalization, d erea lization, ill usions, hallucinations, and synesthesias. In addition, the diagnosis requires that h vo of the following physiological signs are also present: pupilla ry dilation, tachycardia, sweating, palpit<1tions, blurring of vision, tremors, and incoordination (Criterion 0 ). The symptoms must not be due to a general medical condition and are not better accounted for by another mental dis order (Criterion E). Hallucinogen Intoxication usually begins with some s timulant effects such as restlessness and autonomic activation . Nausea may occur. A sequence of exp eriences then follows, with higher doses producing more intense symptoms. Feelings of euphoria may alternate rapidly w ith depression or anxiety. Initial visu al illusions or enhanced sensory experience may give way to hallucinations. At low doses, the per-
292.89
ceptual changes frequently d o not include hallucinations. Synesthesias (a blending of senses) may result, for example, in sounds being "seen. " The hallucinations are usuaUy visu al, often of geometric forms or figures, sometimes of p ersons and objects. r.,'lore rarely, auditory or tactile hallucinations are experienced . In most cases, reality testing is preserved (i .e., the individual knows that the effects are subs tance induced).
e.
Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective intensi fication of perceptions, depersonalization, derealization, i llusions, hallucinations, synesthesias) that developed during, or shortly after, hallucinogen use.
D. Two (or more) of the fo!lowing signs, developing durin g, or shortly after, hallucinogen use:
(1) pupi l lary dilation
E. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
Substance-Related Disorders object as seen in stroboscopic photography), perceptions of entire objects, afterimages (a same-colored or complementary-colored "shadow" of an object remaining after removal of the object), halos around objects, macropsia, and micropsia . The abnormal perceptions that are associated w ith Hallucinogen Persisting Perception Disorder occur episodically and may be self-indu ced (e.g., by thinking about them) or triggered by entry into a dark environment, various drugs, anxiety or fatigu e, or other s tressors. The episodes us ually abate after several months but can last longer. Reality testing remains intact (i.e., the person recognizes that the perception is a drug effect and does not represen t external reality). In contrast, if the person has a delus ional interpretation concerning the etiology of the perceptual disturbance, the appropriate diagnosis would be Psychotic Disorder Not Otherwise Specified.
and infections of the brain, vimal epi lepsies) and are not better accounted for by another mental disorder (e.g., delirium, dementia, Schizophrenia) or hypnopompic hallucinations.
255
with dread of insa nity or d eath. Many hallucinogenic substances have stimulant effects (e.g., tachycardia, mi ld h yp ertension, h yperthermia, and pupillary dilation) and may cause some of the features of Amphetamine Intoxication . The percephlal disturbances and impaired judgment associated with Hallucinogen Intoxication may res ult in injuries or fatalities from automobile accidents, physical fi ghts, or attempts to " fly" fro m high places . Environmental factors and the personality and expectations of the individual using the hallucinogen may contribute to the nature and severity of Hallucinogen Intoxication . Intoxication may also be associated w ith physiological changes, including increases in blood glucose, cortisol, ACTH, and prolactin. Hallucinogen Persis ting Perception Disord er may p roduce considerable anxiety and concern and may be m ore common in suggestible persons. It remains controversial whether the chronic hallucinogen use produces a Psychotic Disorder de novo, triggers psychotic symptoms only in vulnerable persons, or is simply an early and continuing sign of an evolving psychotic process. Hallucinogen Abuse and Dependence also frequentl y occur in persons with preexis ting adolescent Conduct Disorder or adult Antisocial Personality Disorder. LSD intoxication may be confirmed by urine toxicology.
Prevale nce
Hallucinogens came into vogue in the United States in the 1960s. O ver the ye.1rs, a variety of these agents have been popuJar, but in the 1990s the two most commonly used drugs of this class have been LSD and MDlvlA. It is es timated tha t the p eak p revalence o f intake of hallucinogens in the United States was betw een 1966 and abou t 1970, w ith a subsequent decline, but there is some evidence of a modes t increase begirnling in approximately 1990. According to a 1996 national s urvey of drug u se, 10% of people aged 12 and older acknowledged ever having used a hallucinogen. The age group reporting the highes t proportion who had ever used one of these drugs was 18- to 25-year-old s (16%), including 7% in the past year and 2% in the prior month. Am ong high school seniors, data from a 1997 national survey indicated that 15% acknow ledged ever having taken a hallucinogen, including 10% in the prior year. It should be noted that because these surveys measured patterns of use rather than disorders, it is not known how many of those in the survey who used hallucinogens had symptoms that met the cri teria for Dependence or Abuse. A 1992 community survey conducted in the United States reported lifetime rates of Hallucinogen Abuse or Dependence to be about 0.6%, with a 12-month p revalence rate of about 0.1%.
256
Cou rse
Hallucinogen Intoxication may be a brief and isolated event or may occur repeatedly. The intoxication may be prolonged if doses are frequently repeated during an episode. Frequent dosing, however, tends to reduce the intoxicating effects because of the development of tolerance. Depending on the drug and its route of administration, peak effects occur within a few minutes to a few hours, and intoxication ends within a few hours to a few days after dosing ends. The high prevalence of "ever having used" hallucinogens among those ages 26-34 years and the lower prevalence of recent use in that group suggest that many individuals may stop using hallucinogens as they get older. Some individuals w ho use hallucinogen report " nashbacks" that are not associa ted with any impairment o r distress. On the o ther hand, flashbacks can cause impairment or distress in some individuals (Hallucinogen Persisting PercepHon Disorder; see above).
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Hallucinogen-Induced Disorders may be characterized by symptoms (e.g., d elusions) that resemble primary mental disord ers (e.g .. Schizophreniform Disorder versus Hallucinogen-Induced Psychotic Disorder, With Delusions, With Onset During Intoxication). See p. 210 for a discussion of this differential diagnosis. HallUC inogen Intoxication should be differentiated from Amphetamine or Phencyclidine Intoxication. Toxicological tests are useful in making this distinction. intoxication with anticholinergics can a lso produce hall ucinations, but they are often associated with physical findings of pupillary dilation, fever, d ry mou th and skin, flushed fa ce, and visual disturbances. Hallucinogen Intoxication is dis tinguished from the other Hallucinogen-Induced Disorders (e.g., Hall ucinogen-Induced Anxiety Disorder, With Onset During Intoxication) because the symptoms in these latter disorders are in excess of those usually associated with HallUC inogen Intoxication and arc severe enough to warrant independen t clinical attention. HallUCinogen Intoxication is distinguished from Halluci nogen Persisting Perception Disorder (Flash backs) by the fa ct that the latter continues episodically for weeks (or longer) after the most recent in toxication. In HallUCinogen Persisting Perception Disorder, the individual does not believe that the perception represents external reality, whereas a person with a Psychotic Disorder often believes that the perception is real. Hallucinogen Persisting Perception Disorder may be distinguished from migraine, epilepsy, or a neurological condition by neuro-ophthalmological history, physical examination, and appropriate labora tory evaluation.
292.9
The Hallucinogen-Related Disorder Not Otherwise Specified category is for disord ers associated with the use or hallUC inogens that are not classifiable as Hallucinogen Dependence. Hallucinogen Abuse, HallUCinogen Intoxication, Hallucinogen Persisting Perception Disorder, Hallucinogen Intoxication Delirium, Hallucinogen-Induced
Inhalant-Related Disorders
Inhalant-Related Disorders
This section includes disorders induced by inhaling the aliphatic and aromatic hydrocarbons found in substances such as gasoline, glue, paint thinners, and spray paints. Less commonly used are halogenated hydrocarbons (found in cleaners, typewriter correction fluid , spray-<:an propellants) and other volatile compo und s containing esters, ketones, and glycols. The active ingredients include toluene, benzene, acetone, tetrachloroethylene, methanol, and o ther substances. Reflecting different modes of action and profiles of associated problems, disorders arising from the use of anesthetic gases (e.g., ni trous oxide, ether) as well as short-acting vasodilators (e.g., amyl and butyl nitra te ("poppers"]) are described instead under Other (or Unknown) Substance-Related Disorders on p. 294. Most compounds that are inhaled are a mixture of several substances that can produce psychoactive effects, and it is often difficult to ascertain the exact substance responsible for the disorder. Unless there is dear evidence that a single, unmixed substance has been used, the general lerm illhalallt should be used in recording the diagnosis. These volatile substances are available in a wide variety of commercia l products and may be used interchangeably, depend ing on availability and personal preference. Although there may be subtle d ifferences in the psychoactive and physical effects of the different compounds, not enough is known about their differential effects to distinguish among them. All are capable of producing Dependence, Abuse, and Intoxication. Several methods are used to inhale intoxicating vapors. Most commonly, a rag soaked w ith the substance is applied to the mouth and nose, and the vapors are breathed in- a process called "huffing." The substance may also be placed in a paper or plastic bag and the gases in the bag inhaled-a procedure called "bagging." Substances may also be inhaled directly from containers or from aerosols sprayed in the mouth or nose. There are reports of individ uals heating these compounds to accelerate vapori zation. The inhalants reach the lu ngs, bloodstream, and target sites very rapidly. This section contains discussions specific to the Inhalant-Related Disorders. Texts and criteria sets have already been provided for generic aspects of Substance Dependence (p. 192) and Substance Abuse (p . 198) that apply across all substances. The application of these general criteria 10 Inhalant Dependence and Abuse is provided below. However, there are no unique criteria sets for Inhalant Dependence or Inhalant Abuse. A specific text and criteria set for Inhalant Intoxication is also p rovided below. Tolerance has been reported among individuals with heavy use. Although withdrawal-like symptoms have been seen in arumals a fter repeated exposure 10 trichJoroethane, it has not been established that a clinically meaningful withdrawal syndrome occurs in humans. For this reason, the diagnosis of inhalan t withdrawal is not included in this manual. The Inha lant- Induced Disorders (other than Inhalant Intoxication) are described in the sections of the manual with disorders with which
258
Substance-Related Disorders
292.12
292.84
292.89 292.9
304.60
Inhalant Dependence
Refer, in addition, to the text and criteria for Substance Dependence (see p. 192). Some of the generic Dependence criteria d o not appl}' to inhalants, whereas others require further explana tion. Tolerance to the effects of inhalants has been reported among individuals with heavy use, although its prevalence and clinical significance are u nknown. A possible mild withdrawal syndrome has been reported but has not been well documented and d oes not ap pear to be clinically sign ifi can t. TIlUS, Inhalant Dependence includes neither a characteristic withdrawal syndrome nor ev idence of inhalant use to relieve or avoid w ithdrawal symptoms. However, inhalants may be taken over longer p eriod s of time or in larger amounts than was origina lly intended, and individuals who use them may find it d ifficul t to cut down or regulate inhalant use. Because inhalants are inexpensive, legal, and easily available, spending a great deal of time attempting to p rocure inhalants would be rare. H owever, su bstantial amounts of time may be spent on using and recuperating from the effects of inhalant usc. Recurrent inhalant use may result in the individ ual giv ing up or reducing imporI,mt socia l, occupational, or recreational activities, and substance use may continue despite the individual's knowledge of physical problems (e.g., liver d isease or central and periphera l nervous system damage) or psychological problems (e.g., severe depression) caused by the u se.
305.90
259
Specifiers
The fo llowing sp ecifiers may be applied to a diagnosis of Inhalan t Dependence (see p. 195 for more details): Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission In a Controlled Environment
305.90
Inhalant Abuse
Refer, in addition, to the text and criteria for Substance Abu se (see p. 198) . Individuals who abuse inhalants may use them in hazardous circums tances (e.g., driving an automobile or operating machinery when judgment and coordination are impaired by Inhalant In toxication). Users can also become agitated and even violen t during intoxication, w ith s ubsequent legal and interpersonal problems. Repeated intake of inhalants may be associated with family conflict and school problems (e.g., truancy, poor grades, dropping out of sch ool) or difficulties at work.
Inhalant-Induced Disorders
292.89
Inhalant Intoxication
Refer, in addition, to the text and criteria for Subs tance Intoxication (see p. 199). The essential feature of Inhalant Intoxication is the presence of clinically significant maladaptive behavioral or psychological changes (e.g., confusion, belligerence, assaultiveness, apa thy, impaired judgment, impaired social or occupationa l functioning) that develop during, or shortly after, the intentional use of. o r short-term, high-dose exp osure to, volatile inhalants (Criteria A and B). The maladaptive changes are accompanied by signs that includ e dizziness or visual dishtrbances (blurred vision or diplopia), nystagmus, incoordination, slurred speech, an lmsteady gait, tremor, and euphoria. Higher doses of inhalants may lead to the development of lethargy and psychomotor retardation, generalized muscle weakness, depressed reflexes, stupor, or coma (Criterion C) . The distmbance must not be due to a general medical condition and is not better accounted for by another mental disorder (Cri terion D).
Substance-Related Disorders
cluding anesthetic gases and short-acting vasodilators). B. Clinica lly significant maladaptive behavioral or psychologica l changes (e.g., belliger. ence, assaultiveness, apathy. impai red judgment, impaired social or occupational funct ioning) that developed during. or shortly after. use of or exposure to volatile inhalants.
C. Two (or more) of the foll owing signs. developing during. or shortly after. inhalant
dizziness nystagmus incoordination slurred speech unsteady gait lethargy depressed reflexes psychomotor retardation tremor general ized muscle weakness blurred vision or diplopia stupor or coma euphoria
D. The symptoms are not due to a general med ical condition and are not better accounted for by another mental disorder.
262
Substance-Related Disorders
among individuals with heavy use. Recurrent use may lead to the development of hepatitis (which may progress to cirrhosis) or metabolic acidosis consistent with dis tal renal tubular acidosis. Chronic renal failure, h epatorenai syndrome, and proximal renal tubular acidosis have also been reported, as has bone marrow suppression, es pecially w ith benzene and trichloroethylene, with the former possibly increasing the
risk for acute myelocytic leukemia. Some inhalants (e.g., methylene chloride) may be metabolized to carbon monoxide. Death may occur from respiratory or cardiovascular depression; in particular, "sudden sniffing death" may result from acute arrhythmia, hypoxia, o r electrolyte abnormalities.
Preval ence
It is difficult to estabUsh the true prevalence of inhalant use because these drugs are easy to obtain legally, and thei r importance might be underestimated in surveys. In addition, the popularity of different inhalants changes over time, with , for example, a decrease over the pas t decade in the proportion of users prcfcrring glues and aerosols and an increase in those inhaling lighter fluid. A 1996 national survey of drug use reported that around 6% of people in the United States acknowledged ever having used inhalants, with 1% reporting use in the past year and 0.-1% in the past month. The highest lifetime prevalence was seen for 18- to 2S-year-olds (11 1<.), while 12- to 17-}'ear-olds predominated for use in the prior year (4%) or in the prior month (2%). Higher rates are reported among a va riety of subgroups, including almost 30% of p ri son inmates who report ever having used these substances. Rates of use are also higher among populations who live in poverty, especiaUy children and young adults. It shouJd be noted that because these surveys measured patterns of u se rather than disorders, it is not known how many of those in the survey who used inhalants had symptoms that met criteria for Dependence or Abuse. The prevalence of Inhalant Dependence or Abuse in the general p opulation is unknown.
Course
It can be difficult to maldl inhalant dose 10 effect because the different methods of administration and the varying concentra tions of inha lants in the products u sed cause highly variable concentrations in the bod}'. The time course of Inhalant Intoxication is related to the pharmacological characteristics of the s pecific subs tance u sed, but it
292.9
is typica lly brief, lasting from a few minutes to an hour. Onset is rapid, peaking within a few minutes after inhaling. Younger children diagnosed as having Inhalant Dependence may use inhalants several times a week, often on weekends and after school. Severe depend ence in adults may involve varying periods of intoxica tion throughout each day and occasional periods of heavier use that may last several days. This pattern may persist for years, with recurrent need for treatment . Individuals who use inhalants may have a preferred level or degree of intoxication, and the method of administration (typicall)' sniffing from a container or breathing through a rag soa ked in the substance) may allow the individual to maintain that level for several hours. Cases have also been reported of the development of Dependence in industrial workers who have long-term occupational exposure and access to inhalants. A worker may begin to use the compound for its psychoactive effects and subsequently develop a pattern of Dependence. Use leading to Dependence ma y also occur in people who do not have access to o ther substances (e.g., prisoners, isolated military personnel, and adolescents or yOWlg adu lts in isolated rural areas).
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Inhalant-Induced Disorders may be characteri zed by symptoms (e.g., depressed mood) that resemble primary m ental di sorders (e.g., Major Depressive Disorder versus Inhala nt-induced Mood Disorder, With Depressive Features, Wi th Onset During Intoxication). See p. 210 for a discussion of this differential diagnosis. The symptoms of mUd to moderate Inhalant Intoxication can be similar to those of Alcohol In toxicati on and Sedative, Hypnotic, or Anxiolytic Intoxication. Breath odor or residues on bod y or clothing may be important differentia ting clues, but should not be relied on exclusively. lndividuals who chronicaUy use inh alants are likely to use other substances frequentl y and heavily, fur ther complica ting the diagnostic picture. Concomitant use of alcohol may a lso make the differentiation difficult. History of the drug used and characteristic findings (including odor of solven t or paint residue) may diffe rentiate Inhalant Intoxication from other substance in toxications; additionally, symptoms may su bside faster with Inhalant Intoxication than with o ther substance intoxications. Rapid onset and resolution may also d ifferentiate Inhalan t In toxica tion from o ther mental d isorders and neurological conditions. Inhalant In toxication is d istinguished from the o ther Inh alan tInduced Disord ers (e.g., Inhalant-Induced Mood Disorder, With Onset During lntoxication) because the symptoms in these latter disorders are in excess of those usually associated with Inhalant Intoxication and are severe enough to w arrant independent clinical attention. Industrial workers may occasionall}' be accidentally exposed to volatil e chem icals and suffer physiological intoxication. The category "Other Substance-Related Disorders" should be used for such toxin exposures.
264
Substance-Related Disorders
Inhalant Abuse, Inhalant Intoxication, Inhala nt Intoxication Delirium, InhalantInduced Persisting Dementia, Inhalant-Induced Psychotic Disorder, Inhalant-Induced Mood Disorder, or Inhalant-Induced Anxiety Disorder.
Nicotine-Related Disorders
Nicotine Dependence and Withdrawal can develop w ith use of all form s of tobacco (cigarettes, chewing tobacco, snuff, pipes, and cigars) and with prescription medications (nicotine gum and patch). The relative ability of these products to produce Dependence or to induce Withdrawa l is associated with the rapidity characteristic of the route of administration (smoked over oral over transdemlal) and the nicotine content of the product. This section contains discussions specific to the Nicotine-Related Disorders. Texts and criteria sets have already been p rovided to define the generic aspects of Subs tance Dependence (p. 192) that apply across all substances. The application of these general criteria to Nicotine Dep endence is provided below. Reflecting a paucity of clinically relevant data, nicotine intoxication and nicotine abuse are not included in OSM-IV. A specific text and criteria set for N icotine Withdrawal are also provided below. Listed below are the Nicotine-Related Disorders.
Nicotine-Induced Disorder
292.0 292.9 N icotine Withdrawal (see p. 265) N icotine-Related Disorder Not Othenvise Specified (see p . 269)
305.1
Nicotine Dependence
Refer, in addition , to the tex t and cri teria for Substance Dependence (see p. 192). Some of the generic Dependence criteria do not appear to apply to nicotine, wh ereas others require furth er explanation. Tolerance to nicotine is manifes ted by a more intense effect of nicotine the first time it is used during the day and the absence of nausea and dizziness with repea ted intake, despite reg ular use of substantial amounts o f nicotine. Cessation of nicotine u se p roduces a well-defined withdrawal syndrome that is described below. Many individuals who use nicotine take ni cotin e to relieve or to avoid withd rawal symptoms when they wake up in the morning or after being in a situation where use is restricted (e.g., at work or on an airplane). Individuals who smoke and other individuals who u se nicotine are likely to find that they use up their supply of cigarettes or other nicotine-containing products faster than originally in-
292.0
Nicotine Withdrawal
265
tended. Although more than 80% of individuals who smoke express a d esire to stop smoking and 35% try to stop each year, less than 5% are successful in unaided at tempts to quit. Spending a great deal of time in using the substance is best exempli fied by chainsmoking. Because nicotine sources are readily and legally available. spending a great d eal of time attempting to procure nicotine w ould be rare. Giving up important social, occupational, or recreational activities can occur when an indi vidual forgoes an activity because it occurs in smokingrestricted areas. Continued use d espite knowledge of med ical problems related to smoking is a particularly im portant health p roblem (e.g., an individual who continues to smoke d espite having a tobacca.induced general med ica l condition such as bronchitis or chronic obstruc live lung disease).
Specifie rs
The following specifiers may be p. 195 for more details):
ap ~lied
Wi th Ph ysiological Depen den ce Withou t Physiological Dependence Early Full Remi ss ion Early Partial Remission Sustained Full Rem ission Sustained Partial Remission
292.0
Refer, in addition, to the text and criteria fo r Substance Withdrawal (see p. 201). The essential feature of N icotine Withdrawal is the presence o f a characteristic withdraw al syndrome that develops after the abrupt cessation of, or reduction in. the use of n ic oti ne~ontaining products folloWing a prolonged period (a t least several weeks) of daily use (Criteria A and B). The withdrawal syndrome includes four or more of the following: d ysphoric or depressed mood; insomnia; irritability. frustration. or anger; anxiety; difficulty concentrating; restlessness or impatience; decreased heart rate; and increased appetite or weight gain. The withdrawal symptoms cause clinically signif icant distress or impairment in social, occupational, or other important areas of func tioning (Criterion C). The symptoms must n ot be due to a general medical condition and are not better accoun ted for by another mental disorder (Criterion D). These symptoms are in large part due to nicotine deprivation and are typically more intense among individuals w ho smoke cigarettes than among individuals who use other nico ti ne~on taining products. The more rapid onset of nicotine effects w ilh cigarette smoking leads to a more intensive use pattern that is more difficult to give up because of the frequency and rapidity of reinforcement and the g reater physical dependence on nicotine. In individuals who smoke cigarettes. heart rate decreases by 5 to 12 beats per minute in the first few days aft er stopping smoking. and weight
266
Substance-Related Disorders
increases an average of 2-3 kg over the first year after s lopping smoking. Mild symploms of withdrawal may occur after switching to low-tar/ nicotine cigarettes and after
slopping the use of smokeless (chewing) tobacco, nicotine gum, or nicotine patches.
B. Abrupt cessation of nicot ine use, or reduction in the amou nt of nicotine used, followed within 24 hours by four (or more) of the following signs:
(1) dysphoric or depressed mood
. insomnia
restlessness
C. The symptoms in Criterion B cause clinically significant distress or impairment in social. occupational. or other important areas of functioning.
D. The symptoms a re not due to a general medical condition and are not bette r accounted for by another mental disorder.
Nicotine-Related Disorders Associated laboratory findings . Withdrawal symptoms are associated with a slowing on EEG, decreases in catecholamine and cortisolleveis, rapid eye movement (REtvl) changes, impainnent on neuropsychological testing, and decreased metabolic rate. Smoking increases the metabolism of many medications prescribed for the treahnent of mental disorders and of other substances. Thus, cessation of smoking can increase the blood levels of these medications and other substances, sometimes to a clinically significant degree. This effect does not appear to be due to nicotine but rather to other compounds in tobacco. N icotine and its metaboli te cotinine can be measured in blood , saliva. o r urine. Persons who smoke also often have diminished pulmonary function tests and increased mean corpuscular volume (MeV). Associated physical exa mination findings and general medical conditions , icotine Withdrawal may be associated with a dry or productive cough, decreased heart rate, increased appetite or weight gain, and a dampened orthostatic response. The most common signs o f icotine Dependence are tobacco odor, cough, evid ence of chronic obstructive pulmonary disease, and excessive skin wrinkling. Tobacco stains on the fingers can occu r but are rare. Tobacco use can markedly increase the risk of lung, oral, and other cancers; cardiovascular and cerebrovascular conditions; duonic obstructive and other lung diseases; ulcers; maternal and fe tal complications; and other conditions. Although most of these problems appear to be caused by the carcinogens and carbon monoxide in tobacco smoke rather than by nicotine itself, nicotine may increase the risk for ca rdiovascular events. Those who have never smoked but are chronically exposed to tobacco smoke appear to be at increased risk for conditions such as lung cancer and heart di sease.
Prevalence
There were fairl y substantial decreases in regular sm oking and icoline Depend ence in most groups in the 1980s, followed by a leveling off of this rate of decline, estimated to be onJy 2% or less in the late 1990s. Greater levels of decrease were seen for men than for women, and for Caucasian individuals than for those of African American or Hispanic background. Severa l groups have shown an actual increase in the prevalence of regular smoking or Dependence in the mid-1 990s, especia lly women who have less than a high school education.
Substance-Relat ed Disorders
A 1996 national survey of d rug use reported that 72% of the adult population in the United States had ever used cigarettes, with 32% reporting use in the prior }'ear and 29% reporting use in the prior month. The lifetime prevalence in the United States was highest among individuals aged 35 and older (78%), although use in the prior year and prior month was highest for people between ages 18 and 25 (45% and 38%, respectively). The 1996 survey also indicated substantial rates of use of smokeless tobacco, with 17% of the U.s. population acknowledging ever having used these products, and 5% reporting use in the prior month . Surveys of drug use in high school students indicate that tobacco use in the younger population is on the rise. According to a 1997 survey of 12th-g raders, 65% reported ever having used cigarettes-an increase over the 1994 proportion of 62% (but not as high as the peak lifetime prevalence of 76% in 1977). Since it is estimated that behveen 80% and 90% of regular smokers have Nicotine Dependence, up to 25% of the U.s. population may have Nicotine Dependence. The rate of Nicotine Dependence has been shown to be higher in individuals with Schizophrenia or Alcohol Dependence than in the general population.
Course
Nicotine in take usually begins in the early teens, with 95% of those who continue to smoke by age 20 becoming regular daily smokers. More than 80% of smokers report attempting to quit, but during the first attempt, less than 25% of those who do abstain remain successful for extended periods of time. In the longer run, about 45% of those who consume nicotine on a regular basis are able to stop smoking eventually. For the large majority of smokers who have Nicotine Dependence, cessation of cigarette smoking usually results in withdrawal symptoms that begin withi n a few hours of cessation and typically peak in intensity between the first and fourth days, with most residual symptoms greatly improving by 3 to 4 weeks, but with hunger and weight gain p ersisting for 6 months or more. This off-and-on again course and repeated desire for abstinence probably apply equally to consumption of other forms of nicotine, including chewing tobacco.
Familial Pattern
The risk for smoking increases threefold if a first-degree biological relative smokes. Twin and adoption studies indicate that genetic factors contribute to the onset and continuation of smoking, with the degree of heritability equivalent to tha t observed with Alcohol Dependence.
Differential Diagnosis
For a general discussion of the differential d iagnosis of Substance-Related Disorders, see p. 207. The symptoms of Nicotine Withdrawal overlap with those of other substance withdrawal syndromes; Caffeine Intoxication; Anxiety, Mood, and Sleep Disorders; and m edicati on-induced akathisia. Admission to smokefree inpatient units can induce withdrawal symptoms that might mimic, intensify, or disguise other diagnoses. Re-
292.9
duction of symptoms associated with the resumption of smoking or nicotine-replacement therapy confirms the diagnosis.
Because reguJar nicotine use does not appear to impair mental functi oning, Nicotine Dependence is not readily confused with other Substance-Related Disorders and mental disorders.
Opioid-Related Disorders
The opioids includ e natural opioids (e.g., morphine), sem isynthetics (e.g., heroin), and synthetics with morphine-like action (e.g., codeine, hydrom orphone, methadone, oxycodone, meperidine, fen tanyl). Med ications such as pentazocine and buprenorphine that have both opiate agonist and antagonist effects are also included in this class because, especially at lower doses, their agonist properties produce similar phYSiological and behaviora l effects as classic opioid agonists. Opioids are prescribed as analgesics, anesthetics, antidiarrheal agents, or cough suppressants. Heroin is one of the most commonly misused drugs of this class and is usually taken by injection, although it can be smoked or "snorted" when very pure heroin is available. Fentanyl is injected, whereas cough suppressants and antidiarrheal agents are taken orally. The other opioid s are taken both by injection and orally. This section contains discussions specific to the Opioid-Related Disorders. Texts and criteria sets have already been provid ed for the generic aspects of Substance Dependence (p. 192) and Substance Abuse (p. 198) tha t apply across all substances. The application of these general criteria to Opioid Dependence and Abuse is provided below. However, there are no unique criteria sets for Opioid Dependence and Opioid Abuse. Specific text and criteria sets for Opioid Intoxica tion and Opioid Withdrawal are also provided below . The Opioid-lnduced Disorders (other than Opioid intoxication and Withdrawal) are d escribed in the sections of the manual w ith d isorders with which they share phenomenology (e.g., Opioid-Induced Mood Disorder is included in the "Mood Disorders" section). Listed below are the Opioid Use Disorders and the Opioid-Induced Disord ers.
270
Opioid-Induced Disord ers
292.89 292.0 292.81 292.11 292.12
Substance-Related Disorde rs
292.84 292.89
292.89
O pi oid Intoxicati on (see p . 271) Specify if: With Perce ptual Dis turbances Opioid With drawal (see p . 272) Opioid Intoxication Delirium (see p . 143) O pioid-Induced Psychotic D isorde r, With Delusio ns (see p . 338) Specify if: With Onset During Intoxication Opioid-Induced Psychotic Di sorder, With Hallucinations (see p. 338) Specify if: With Onset During Intoxication Opioid-Induced Mood Disorder (see p . 405) Specify if: With Onset During Intoxica tion Opioid-In duced Sexu al D ysfun ction (see p . 562) Specify if: With Onset During In toxication O pi oid-Indu ced Sleep Disorde r (see p. 655)
304.00
Opioid Dependence
Refer, in addi tion, to the text and criteria for Subs tance Dependence (see p. 192). Most indi viduals with O pioid Dependence have significant levels of tolerance and will experience w ithdrawal on abrupt discontinuation of opioid substances. Opioid Dependence includes signs and symptoms that renect compulsive, prolonged selfadministration of op ioid s ubs tances that are used for no legitima te medical purpose or, if a general medical condition is present that requires opioid treatment, that are used in d oses that are greatly in excess of the amo unt needed for pain relief. Persons with Opioid Dependence tend to d evelop such regular pa tterns of compulsive drug use that daily activities are typica lly p lanned around obtaining and administering opioid s. Opioids are us ually purchased on the illega l market but may a lso be obtained from p hysicians by faking or exaggerating general medical problems or by receiving simultaneou s prescrip tions from severa l physicians. Health care profes sionals with Opioid Dependence w ill often obtain opioid s by w riting prescriptions for themselves or by diverting opioids that have been prescribed for patients or from phannacy supplies.
305.50
Opi o id Abuse
271
Specifiers
The following specifiers may be applied to a diagnosis of Opioid Dependence (see p. 195 for more detail s); With Physiological Dependence Without Physiological Dependence Early Full Remi ssion Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled Environment
305.50
Opioid Abuse
Refer, in addition, to the text and criteria for Substance Abuse (see p. 198). Legal difficulties may arise as a result of behavior while intoxica ted with opioids or because an individual has resorted to illega l sources of supply. Persons who abuse opioids typically use these su bstances much less often than do those w ith d ependence and do not develop significant withdrawa l symptoms. \t\'hen problems related to opioid use are accompanied by evidence of withdrawal or compulsive behav ior related to the use of opioi ds, further info rmation should be gathered to see if a d iagnosis of Opioid Dependence, rather than Opioid Abuse, is m ore appropriate.
Opioidlnduced Disorders
292.89
Opioid Intoxication
Refer, in addition, to the tex t and criteria for Substance Lntoxication (see p. 199). The essen tial feature o f O pioid Intoxication is the presence of clinically significant maladaptive behaviora l or psychological changes (e.g., ini tial euphoria followed by apathy, dysph oria, psychomotor agitation or retardation, impaired judgnlent, or impaired social or occupa tional nUlctionin g) that develop during, or shortly after, opioid use (Criteria A and B). Intoxication is accompanied by p upillary constriction (unless there has been a severe overdose with consequent anoxia and pupillary dilation) and one or more o f the following signs: d rowsiness (d escribed as being "on the nod ") or even coma, slurred speech, and impairment in atten tion or memory (Criterion C). individ uals w ith Opioid Intoxica tion may demonstrate i.nattention to the environmen t, even to the point of ignoring potentially hannful events. The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D). TIle magn itude of the behavioral and physiological changes that result from opioid use depends on the dose as well as characteristics of the individual using the substance (e.g., tolerance, rate o f absorption, chronidty of use). Symptoms o f Opioid Intoxication usually last for several hours, a time fram e that is consistent with the half life of most opioid drugs. Severe intoxication following an apioid overdose can lead to carna, respiratory depression, pupillary dilation, unconsciousness, and even d eath.
Specifie r
The following specifier may be applied to a diagnosis of Opioid Intoxication: With Perceptual Disturbances. This specifier may be noted in the rare instance in which hall ucina lions with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Ill tact reality testillg means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucina tions occur in the absence of intact real ity testing, a diagnosis ofSubstance-lnduced Psychotic Disorder, With Hallucinations, shou ld be considered.
euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, im pa ired judgment, or impaired social or occupational functioning) that developed during, o r shortly after, opioid use.
e.
Pupi llary constriction (or pupi ll ary d ilation due to anoxia fr om severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use:
(1) drowsiness or coma (2) slurred speech (3) impairment in atte ntion or memory
O. The symptoms are not due to a general medical condition and a re not better ac-
292 .0
Opioid Withdrawal
Refer, in addition. to the text and criteria for Substance Withdrawal (see p. 201). The essential feature of Opioid Withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of (or reduction in) opioid use that has been heavy and prolonged (Criterion Al). The withdrawal syndrome can be also precipitated by administration of an opioid antagonist (e.g . naloxone or naltrexone) after a period of opioid use (Criterion Al). Opioid Withdrawal is characterized by a pattern of signs and symptoms that are opposite to the acute agonist effects. The first of these are subjective and consist of complaints of anxiety. restlessness. and an "achy feeling " that is often loca ted in the back and legs. accompanied by a wish to obtain opioids ("craving") and drug-seeking behavior. along with irri tabili ty and increased sensitivity to pain. Three or more of the foUowing must be present to make a diagnosis of Opioid Withdrawal: dysphoric mood; nausea or vomiting; muscle aches;
273
lacrimation or rhinorrhea; pupillary dilation, piloerection, or increased sweating; di arrhea; yawning; fever; and insomnia (Criterion B). Piloerection and fever are associ atec! with more severe withdrawal and are not often seen in routine clinical practice because individuals with Opioid Dependence usually obtain substances before withdrawal becomes that far advanced. These symptoms of Opioid Withdrawal must cause clinically significant distress or impainnent in social, occupational, or other important areas of ftmctioning (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D). In most individuals who are dependen t on short-acting drugs such as heroin, withdrawal symptoms begin within 6-12 hours after the last d ose. Symptoms may take 2-4 days to emerge in the case of longer-acting drugs such as methadone or LAAM (L-alpha-acety lmethadol). Acute withdrawal symptoms for a short-acting opioid such as heroin usually peak within 1- 3 days and gradually subside over a period of 5-7 days. Less acu te withdrawal symptoms can last for weeks to months. These more cluonic symptoms include anxiety, d ysphoria, anhedonia, insomnia, and drug craving. Virtually all ind iv iduals with Op ioid Dependence report a ph)'siological component, including 50% who have experienced withdrawal.
(several weeks or longer) (2) administration of an opioid antagonist after a period of opioid use 8. Three (or more) of t he following, developing within minutes to several days after Cri terion A:
(1) dysphoric mood
nausea or vomiting muscle aches lacrimat ion or rhinorrhea pupi llary dilation, piloerection, or sweati ng dia rrhea yawning fever insomnia
C. The symptoms in Crit erion 8 cause clinically significant distress or impairment in so cia l, occupational, or other importa nt areas of functioning .
D. The symptoms are not due to a general medical condition and are not better accounted for by anot her mental disorder.
274
Substance-Related Disorders
275
and C are positive in as many as 800 .......90% of intravenous users, either for hepatitis an/ tigen (signi fying active infection) or hepatitis antibody (signifying past infection). Mildly elevated liver function tests are common, either as a result of resolving hepatitis or from toxic injury to the liver due to contaminants that have been mixed with the injected opioid . Subtle changes in cortisol secretion patterns and bod y temperature regulation have been observed for up to 6 months following opioid detoxification.
Associated physical examination findings and general medical conditions . Acute and chronic opioid use are associated with a lack of secretions, causing dry mouth and nose, slowing o f gastrointestinal activity, and constipation. Visual acuity may be impaired as a result of p upillary constriction. In individuals who use opioids intravenously, sclerosed veins (" tracks") and puncture marks on the lower portions of the u pper extremities are common. Veins sometimes become so badly sclerosed that peripheral edema d evelops and ind ividuals switch to veins in the legs, neck, or groin. When these veins become unusable or o therwise lmavailable, individuals often inject directly into their subcutaneous tissue ("skin-popping"), resulting in ceUulitis, abscesses, and circular-appearing scars from healed skin lesions. Tetanus and Clostridilllll boil/lillI/ill infections are relatively rare but extremely serious consequences of injecting opioids, especially with contaminated needles. Infections may also occur in other organs and include bacterial endocarditis, hepatitis, and human immunodeficiency virus (HIV) infection. Tuberculosis is a particularly serious p rOblem among individuals w ho use drugs intravenously, especially those depend ent on heroin. Infection with the tubercle bacillus is usually asymptomatic and evident only by the presence of a positive tubercu lin skin lest. However, many cases o f active tuberculosis have been found, especially among those who are infected w ith HI V. These individuals often have a newly acqUired infection, bu t also are likely to experience reactivation of a prior infection due to impaired immune function. Persons who sniff heroin or other opioids ("snorting") often develop irritation of the nasal mucosa, sometimes accompanied by perfo ration of the nasal septum. Difficullies in sexual functioning are common. Males often experience erectile d ysfunction during intoxication or ch ronic use. Females commonly have disturbances of reproducth'e function and irregular menses. The incidence of HIV infection is h.igh among individuals w ho use intravenous drugs, a la rge proportion of whom are individuals with Opioid Dependence. HIV infection rates have been reported to be as high as 60% among persons dependent on heroin in some areas of the United States. In add ition to infections such as cellulitis, hepatitis, HIV, tuberculosis, and endocarditis, Opioid Dependence is associated with a death rate as high as 1.50/ 2% per ....... year. Death most often results from overdose, accidents, injuries, AIDS, or other general medical complications. Accidents and injuries due to violence that is associated with buying o r selling drugs are common. In some areas, violence accounts for more opioid-related dea ths than overd ose or HfV infection. Physiologica l dependence on opioids may occur in about half of the infants born to females w ith Opioid Dependence; this can produce a severe withdrawal syndrome requiring medical treatment. Although low birth weight is also seen in children of mothers with Opioid Dependence, it is usually not marked and is generally not associated with serious adverse consequences.
Substance-Related Disorders
Preva lence
A 1996 national survey of drug use reported that 6.7% of men and 4.5% of women in the United States acknowledged ever using an analgesic drug in a manner other than that for which it was prescribed, including 2% who had used these drugs in the prior year and approximately 1% who had taken these drugs in the prior month. The medically inappropriate use of analgesics had its highest lifetime prevalence among individuals behveen ages 18 and 25 (9%), with 5% in this age g roup acknowledging ever having taken the drug in the prior year, and 2% acknowledging ever having taken the drug in the prior month . The lifetime preva lence for heroin use was around 1%, with 0.2% ha\' ing taken the drug during the prior year. A 1997 survey of drug use among high school students reported that around 2% of high school seniors had ever taken heroin and 10% acknowledged the inappropriate use of other "analgesics." These lifetime heroin rates for high school seniors are higher than the 1990 and 1994 ra les (1.3% and 1.2%, respectively) and represent the highest figures since the 1975 rate of over 2%. Because the surveys assessed patterns of use rather than disorders, it is not known how many of those who used analgeSiCS or heroin had symptoms that met criteria for Dependence or Abuse. A community study conducted in the United States from 1980 to 1985 thelt used the more narrowly defined DSM-llI criteria found that 0.7% of the adult population had Opioid Dependence or Abuse at some time in their lives. Among those individuals with Dependence or Abuse, 18% reported use in the last month and 42% reported having had a problem with opioids in the last year.
Course
Opioid Dependence can begin at any age, but problems associated with opioid use are most commonly first observed in the late teens or early 20s. Once Dependence develops, it usually continues over a period of many years, even though brief periods of abstinence are frequent. Relapse following abstinence is common. Although relapses do occur, and while some long-term mortality rates have been reported to be as high as 2% per year, about 20%-30% of individuals with Opioid Dependence
292.9
achieve long-term abstinence. An exception to the chronic course of Opioid Dependence was observed in service personnel who became dependent on opioids in Vietnam. On their return to the United States, less than 10% of those who had been dependent on opioids relapsed, although they experienced increased rates of Alcohol or Amphetamine Dependence. Few data are ava ilable on the course ofOpioid Abuse.
Famili al Pattern
The family members of individua ls with Opioid Dependence are likely to have higher levels of psychopathology, especially an increased inddence of other SubstanceRela ted Disorders and Antisocial Personality Disorder.
278
Phencyclidine-Induced Disorders
292.89 292.81 292.11 292.11 292.84 292.89 292.9 Phencyclidine Intoxication (see p. 280) SpecifiJ if With Perceptual Disturbances Ph encyclidine Intoxication Delirium (see p. 143) Phencyclidine-In d uced Psychotic D isorder, With Delusions (see p. 338) Specify if: With Onset During Intoxication Phencyclidine-Induced Psychotic Disorder, With Hallucin ations (see p. 338) Specify if: With Onset During Intoxication Phencycl idine-Ind uced Mood Disorder (see p. 405) SpecifiJ if: With Onset During Intoxication Phencyclidine-Induced Anxiety Disorder (see p. 479) Specify if: With Onset During Intoxication Phencyclidin e-R elated Disorder Not Oth en .... ise Specified (see p. 283)
304.60
279
304.60
Refer, in addition, to the text and criteria for Substance Dependence (see p . 192). Some of the generic criteria for Subs tance Depend ence do not apply to phencyclidine. Although "craving" has been reported by ind ividuals w ith heavy use, nei ther tolerance nor withdrawal symptoms ha ve been clearly d emonstrated in humans (although both have been sh own to occur in animal studies). Phencyclidine is us ually not difficult to obtain, and individ uals with Phencyclidine Dependence often use it at least two to three times per d ay, thliS spending a significant proportion of their time using the substance and experiencing its effects. Phencyclidine use may continue despi te the presence of psychological p roblems (e.g ., d isinhibition, anxiety, rage, aggression, panic, fla shbacks) or medical prob lems (e.g ., hyperthennia, hyp ertension, seizures) that the ind ividual knows are cau sed by the subs tance. Ind ividuals w ith Phencyclidine Dependence can manifest d an gerous behavioral reactions due to lack of insight and judgment while intoxicated . Aggressive behavior involving fighting-probably the result of disorganized thinking, agitation, and impaired judgment- has been identified as an especially problematic adverse effect of phencyclidine. As with hallucinogens, ad verse reactions to phencyclid ine may be more common among individuals w ith preexis ting mental d isorders.
Speci f ie rs
The following specifi ers may be applied to a diagnosis of Phencyclidine Dependence (see p . 195 for m ore details) : Early Full Remission Early Partial Rem ission Su stained FuJI Remission Sus tained Parti al Remi ssion In a Con troll ed Environm ent
30 5.90
Refer, in addition, to the text and cri teria for Subs tance Abuse (see p . 198). Although in dividuals who abuse phencyclidine u se the subs tance much less often than those with Dep endence, they may repeatedly fail to ful fill major role obligations at school, work, or home becau se o f Phencyclidine Intoxication. Individuals may use phencyclidine in situations where it is physically hazardous (such as while operating heavy machinery or driving a motorcycle or car). Legal difficulties may arise d ue to p ossessi on of phencyclidine or to behaviors resu lting from Intoxica tion (e.g., fig hting) . There may be recurrent social or interpersonal problems d u e to the individual's behavior while intoxicated or to the chaotic lifestyle, multiple legal p roblems, or arguments with significant others.
280
Phencyclidine-Induced Disorders
292.89
Phencyclidine Intoxication
Refer, in addition, to the text and criteria for Substance Intoxication (see p. 199). The
essential feature o f Phencyclidine Intoxication is the presence of clinically significant maladaptive behavio ra l changes (e.g., belligerence, assa uitiveness, impulSiveness, unp redictability, psych omotor agitation, impaired judgment, or impaired social or occupational fun ctioning) that d e velo p during, or s hortly after, use of phe ncyclidine (or a related s ubstance) (Criteria A and B). These changes a re accompanied by h\'o or more of the follo w ing signs that d evelop within an ho ur of us ing the subs tance (or less when it is smoked, "snorted," or used intravenously): vertical or horizontal nys-
tagmus, hyp ertension or tachyca rdia, numbness or diminished responsiveness to pain, ataxia, d ysarthria, muscle rigidity, seizures or coma, and hyperacusis (Criterion C) . The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D). Specific signs and symptoms are dose related. Lower doses of phencyclidine produce vertigo, ataxia, nystagmus, mild hypertension, abnormal involuntary movements, slurred speech, nausea, weakness, slowed reaction times, euphoria or affective dulling, and lack of concern. Disorganized thinking, changed body image and sensory perception, depersonaliza tion, and fee lings of unreality occur at intermediate doses. There is evidence tha t individuals with Schizophrenia may experience an exacerbation of psychotic symptoms. Higher doses produce amnesia and coma, with analgesia sufficient for surgery, and seizures with respiratory depression occur at the highest doses. Effects begin almost immediately after intravenous use or smoking, reaching a peak within minutes. Peak effects occur about 2 hours after oral doses. In milder intoxications, the effects resolve after 8-20 hours, w hereas signs and symptoms of severe intoxications may persist for several days. Phencyclidine-Induced Psychotic Disorder (p . 338) may persist for weeks.
Specifier
The following specifier may be applied to a diagnosis of Phencyclidine Intoxication: With Percep tual Disturbances. This specifier may be noted when hallucinations with intact reality testing or auditory, visual. or tactile illusions occur in the absence of a delirium . Illtact reality testjug means that the person knows that the hallucinations are ind uced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced PSydlOtic Disorder, With Hallucinations, should be considered.
281
8 . Clinically sig nif icant maladaptive behaviora l changes (e.g., belligerence, assaultiveness, impulsive ness, unpredictability, psychomotor agitation, impaired judgment, or impaired social o r occupat ional functio ning) that developed during, or shortly after, phencyclidine use.
e.
Within an hour (less when smoked, "snort ed," or used intravenously), two (or more) of the follow ing signs:
vertical or horizontal nystagmus hypertension or tachycardia numbness o r dimin ished responsiveness t o pain ataxia dysarthria muscle rigidity seizures or coma hyperacusis
D. The symptoms are not d ue t o a general medical condition and are not better accounted for by another menta l disorder.
Specify if:
282
Substance-Related Disorde rs
tions may lead to job, family, social, or legal problems. Violence, agitation, and bizarre behavior (e.g., confused wandering) may occur. Individuals with Phencyclidine Dependence or Abuse may report repea ted intoxication-induced hospitalizations, emergency-room visits, and arrests fo r confused or bizarre behavior or for fighting . Conduct Disorder in adolescents and Antisocial Personality Disorder in adults may
be associa ted with phencyclidine use. Dependence on other substances (especially cocaine, alcohol, and amphetamines) is common among those w ho have Phencyclidine
Dependence.
Associated laboratory find ings. Phencyclidine (or a related s ubstance) is present in the urine of individuals who are acutely intoxicated with one of these substances. The substance may be detectable in urine for several weeks after the end of prolonged or very high dose use because of its high lipid solubility. Phencyclidine may be detected more readily in acidic urine. Creatine phosphokinase (CPK) and serum glu tamic-oxaloacetic transaminase (SGOn are often elevated, reflecting muscle damage.
Associated physical examination findings and gen e ral medical conditions. Phencyclidine Intoxication produces extensive cardiovascular and neurological (e.g., seizures, dys tonia s~ d yskinesias, catalepsy, and h ypothermia or hyperthermia) toxicity. Since almost half of individuals with Phencyclidine Intoxication present with nystagmus or elevated blood pressure, these physical signs can be useful in identifying a phencyclidine user. In those with Phencyclidine Dependence o r Abuse, there may be physical evidence of injuries from accidents, fights, and fa lls. Needle tracks, hepatitis, human immunodeficiency virus (HIV) disease, and bacterial endocarditis may be fo und among the relatively few individuals who take p hencyclid ine intravenousI}'. Drowning, even in small volumes of water, has been reported. Respira tory problems arise with apnea, bronchospasm, bronchorrhea, aspiration during coma, and hypersalivation. Rhabdomyolysis with renal impairment is seen in about 2"10 of individua ls who seek emergency care. Cardiac arrest is a rare outcome.
Preva lence
Medical examiners nationally report that phencyclidine is involved in abou t 3% of deaths associated w ith substance use. It is men tioned as a problem in about 3% of substance-related emergency-room visits. According to a 1996 national survey of d rug lise in the United States, more than 3% of those age 12 and o lder acknowledged ever lIsing p hencyclidine, w ith 0.2% reporting use in the prior year. The highest li fetime prevalence was in those aged 26-34 years (4%), while the highest proportion using phencyclidine in the prior year (0.7%) was in those aged 12-17 years. It should be noted that because these surveys measured patterns of use r<lther than disorders, it is
292.9
283
not known how many of those in the su rvey who used p hencyclidine had symptollls that Illet cri teria for Dependence or Abuse. The p revalence of Phencyclid ine Dependence or Abuse in the general popula tion is unknown.
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Phencyclid ine-Induced Disord ers may be characterized by symptoms (e.g., depressed mood) th at resemble prim ary mental disorders (e.g., Major Dep ressive Disorder versus Phencycl idine-Induced Mood Disorder, With Dep ressive Fea tures, With Onset During Intoxication). See p. 210 for a discu ssion of this differential diagnosis. Recurring episodes of pSydlOtic or mood symptoms due to Phencyclidine Intoxication may mimic Schizophrenia or Mood Diso rd ers. History or laboratory evidence o f p hencyclidine use es tablishes a role for the substance but does not rule out the co-occurrence of other prim ary menta l d isord ers. Rapid onset of symptoms, presence of delirium , or observation of nystagmus or hypertension also suggests Phencyclidine Intoxica tion rather than Sch izophrenia, but phencyclidine use may induce acute psychotic episodes in individuals with preexisting Schizophrenia. Rapid resolution of symptoms and the absence of a history of Schizophren ia may aid in this differentiation. Drug-rela ted violence or impaired ju dgment may co-occur with, or may mimic aspects of, Conduct Disorder or Antisocial Personality Disorder. Absence of behavioral problems before th e onset of substance use, o r during abstinence, may help to clarify this differentiation. Phencyclidine and related substances may produce perceptual disturbances (e.g., scintillating Lights, perception of sounds, illusions, or fo rmed visual images) that the person usually recognizes as resulting from the drug use. If rea lity testing remains intact and the person nei ther believes that the perceptions are real nor acts on them, the specifier Wi th Perceptual Distu rbances is noted for Phencyclidine Intoxication. If reali ty testing is impaired, the diagnosis of Phencyclidine-Induced Psychotic Diso rder should be considered . Differentiating Phencyclidine Intoxication from other Substance Intoxications (with which it often coexis ts) depend s on a history of ha\'ing taken the substance, the p resence of d laracteristic findin gs (e.g., nystagmus and mild hypertension), and positive urine toxicological tests . individ uals who use phencyclid ine often use other drugs as well, and comorbid Abuse or Dependence on other drugs must be consid ered. Phencyclidine In toxica tion is distinguished from the o ther Phencyclidin eInduced Disorders (e.g., Phencyclidine-Induced f\'[ood Disorder, With Onset During Intoxication) because the symptoms in these latter d isorders are in excess of those usually associa ted with Phencyclidine Intoxication and are severe enough to warrant independent clinical attention.
292.9
The Phencyclidine-Rela ted Disorder Not Otherwise Specified ca tegory is for disorders associated with the use of phencyclidine that are not classifiable as Phencycli-
284
dine Dependence, Phencyclidine Abuse, Phencyclidine Intoxication, Phencyclidine Intoxication Delirium, Phencyclidi.ne-Induced Psychotic Disorder, PhencyclidineInduced Mood Disorder, or Phencyclidine-Induced Anxiety D isorde r.
304. 10
285
292.12
292.84
292.9
Sedative, Hypnotic, or Anxiolyti c Intoxication (see p. 286) Sedative, Hypnotic, or Anxiolyti c Withdra wal (see p. 287) Specify if: With Perceptua l Disturbances Sedative, Hypnotic, or Anxiolytic In toxication Delirium (see p. 143) Sedative, Hypnotic, or Anxioly lic Withdrawal Delirium (see p. 143) Sed ative-, Hypn otic-, o r Anxiolytic-Ind uced Persisting Demen ti a (>ee p . 168) Sedati ve-, Hypn otic-, or An xioly tic-In duced Persisting Amn es ti c Disord er (see p . 177) Sedative-, Hypnotic-, or Anxioly tic-lnduced Psych otic Disorder, With Delusion s (see p. 338) Specify if: With Onset During Intoxication / "Vith Onset During Withdrawal Sed ative-, Hypno tic-, or Anxiolytic-Indu ced Psych ot ic Disorder, With Hallucinations (see p. 338) Specify if: '''' ith Onset During Intoxication / With Onset During W ithd rawal Sedative-, Hypn otic-, or Anxiolytic-Induced Mood Disorder (see p . 405) Specify if: With Onset During Intoxica tion / With O nset During Withd rawal Sedative-, H ypnotic-, or Anxiolytic-In duced Anxiety Disord er (see p. 479) Spl.'cifiJ if: With Onset During Withd raw al Sed ative-, Hyp notic-, o r Anxiolytic-Induced Sexual Dysfunction (see p . 562) Specify if: Wi th Onset During In toxication Sedative-, Hypn otic-, o r Anxioly tic-Indu ced Sleep D isorder (see p. 655) SpecifiJ if: With Onset During In toxica tion / With Onset During Withd rawal Sed ative-, Hypnoti c-, or Anxiolyti c-Rela ted Di sorder Not O then vise Sp eci fi ed (see p. 293)
286
of a d elirium that can be life threatenin g. There may be evidence of tolerance and withdrawal in the absence of a d iagnosis of Substance Dependence in an indiv idual who has abruptly discontinued benzod iazepines that were taken for long periods of time at prescribed and therapeu tic d oses. A diagnosis of Subs tance Dependence should be considered only when, in addition to havin g physiologica l d ependence, the individual using the substance shows evidence of a range of p roblems (e.g., an individ ua l wh o has developed d rug-seeking beha vior to the extent that important acti vit ies are given u p or reduced to obtain the su bstance).
Specif iers
The following specifiers may be ap p lied to a diagnosis of Seda tive, Hypnotic, o r Anxiolytic Dependence (see p. 195 fo r more details); With Physiol og ical Depen dence Without Physiolog ica l Dependence Early Full Remission Early Partial Rem ission Sustained Full Rem ission Sus tained Partial Rem ission In a Con trolled Environ ment
305.40
Refer, in add ition, to the text and cri teria for Substance Abuse (see p. 198). Abuse of substances from this class may occur on its own or in conjunction w ith use of o ther substances. For example, ind ivid uals may use intoxica ting d oses of sedatives or benzodiazepines to "come d own " fro m cocaine o r ampheta mines or use high doses of benzodiazepin es in combina tion with methadone to "boost" its effects. Abuse of substances from this class may result in use in hazardous situations, such as getting "high" and then d riving. The individual may miss work o r school o r neglect h ome d uties as a result of intoxication or get into arguments w ith spouse or parents about epi sodes o f substance use. When these problems are accompan ied by evidence of to lerance, w ithdrawal, or compu lSive behavior related to the use o f sedatives, hypnotics, or anxiolytics, a d iagnosis of Sedative, Hypnotic, o r Anxiolytic Dependence should be considered .
287
priatc sexual or agg ressive behavior, mood lability, imptlired judgment, impaired social or occupational fun ctioning) that develop during, or s hortly after, usc of a sedative, hypnotic, or anxiolytic s ubstance (Criteria A and B). As with other bra in depressants such as alcohol, these behaviors may be accompanied by s lurred s peech, an uns teady gait, n ystagmus, memory o r attentional problems, levels of incoordination that can interfere with d riving abilities and with performing usual activities to the point of causing fa Us or au tomobile accidents, and stupor or coma (Criterion C). Memory impairment is a prominent featu re of Sedative, H ypnotic, or Anxiolytic intoxication and is mos t often characterized by an anterograde amnesia that resembles "alcoholic blackouts," whidl can be quite d is turbing to the individual. The symptoms mu st not be due to a ge neral medical condition and are not beNer accounted for by another mental disorder (Cri terion D). Intoxication may occ ur in individuals who are receiving these substances by prescription, are borrowing the medication from fri ends or relatives, or are deliberately taking the substance to achieve intoxication.
e.
One (or more) of the fo llowing signs, developing during, or shortly after, sedative, hypnotic, o r anxiolytic use: (1) (2) (3) (4) (5) (6) sl urred speech incoordination unsteady gait nystagmus impairment in attention or memory stupor or coma
D. The sym ptoms are not d ue to a general medical condition and a re not better accounted fo r by another mental disorder.
288
Substance-Related Disorders
blood pressure, or body temperature, along with sweating); a tremor of the hands; insomnia, anxiety, and nausea sometimes accompanied by vomiting; and psychomotor agitation . A grand mal seizure may occur in perhaps as many as 200/ .-30% of individ. uals undergoing untreated withdrawal from these substances. In severe Withdrawal, visuaL tactile, or auditory hallucinations or illusions can occur but are us ually in the context of a delirium. If the person 's reality testing is intact (i .e., he or she knows the substance is causing the hallucinations) and the illusions occur in a clear sensorium, the sp ecifier With Perceptual Disturbances can be noted (see below). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms mus t not be due to a general medical cond ition a nd are not better accounted for by another menta) disorder (e.g., Alcohol Withdrawal or Generalized Anxiety Disorder) (Criterion 0 ). Relief of w ithdrawal symptoms with adminis tration of any sedative-hypnotic agent would support a diagnosis of Sedative, H ypnotic, or Anxiolytic Withdrawal . The withdrawal syndrome is characterized by signs and symptoms that are generally the opposite of the acute effects that are likely to be observed in a firs t-time user of these agents. The time course of the withdrawal syndrome is generally predicted by the half-life of the substance. Medications whose actions typically last about 10 hours or less (e.g., lorazepam, oxazepam, and temazepam) produce withdrawal symptoms w ithin 6-S hours of decreasing blood levels that peak in intensity on the second day and improve markedly by the fourth or fifth day. For substances with longer half-lives (e.g., diazepam), symptoms may not develop for more than a week, peak in intensity during the second week, and decrease markedly during the third or fourth week. There may be additional longer-term symptoms at a much lower level of intensity that persist for several months. As w ith alcohol, these lingering withdrawal symptoms (e.g., anxiety, moodiness, and trouble sleeping) can be mistaken for non-substance-induced Anxiety or Depressive Disorders {e.g ., Generalized Anxiety Disorder}. The longer the substance has been taken and the higher the dosages used, the more likely it is that there will be severe Withdrawal. However, Withdrawal has been reported with as little as 15 mg of diazepam (or its equivalent in other benzodiazepines) w hen taken daily for several months. Dosages of approximately 40 mg of diazepam (or its equivalent) daily are more likely to produce clinically relevant withdrawal symptoms, and even higher doses (e.g ., 100 mg of diazepam) are more likely to be followed by withdrawal seizures o r deliriwn. Sedative, H ypnotic, or Anxiolytic Wi thdrawal Delirium (see p. 143) is characterized by disturbances in consciousness and cognition, with vis ual, tactile, or auditory hallucinations. \oVben present, Sedative, H ypnotic, or Anxiolytic W ithdrawal Deliriwn should be diagnosed instead of Withdrawal.
Specifier
The following specifier may be applied to a diagnosis of Sedative, H ypnotic, or Anxiolytic Withdrawal: With Perceptual Disturbances. This specifier may be noted when hallucinations with intact reality testing o r auditory, visual, or tactile illusions occur in
the absence of a delirium. Intact reality testing means that the p erson knows that the haUucinations are induced by the substance and d o not represent external reality. When hallucinations occur in the absence of intact reality testing. a diagnosis of Substance-Induced Psychotic Disord er, With Hallucinations, shou ld be considered.
B. Two (or more) of the followin g. developing within several hours to a few days after Crit erion A:
(1) (2) (3) (4) (5) (6) (7) (8)
autonom ic hype ractivity (e.g . sweating or pulse rate greater than 100) increased hand tremor insomnia nausea or vomiting transient visual. tactile. or aud itory hallucinations or illusions psychom otor ag itation anxiety grand mal sei zures
Specify if:
290
Sed ative, Hypnotic, or Anxiolytic Withdrawal only when the symptoms are in excess of those us ually associated with the Sedative, Hypnotic, or Anxiolytic Intoxication or Withdrawal syndrome and when the symptoms are sufficiently seve re to warrant ind ependent clinical attention.
291
ated with a deterioration in vital signs that may signal an impending medica l emergency (e.g., respiratory arrest from barbiturates). There may be consequences of trauma (e.g., internal bleeding or a subdural hematoma) from accidents that occur while intoxicated. Intravenous use of these substances can result in medical complications rela ted to the use of contaminated needles (e.g., hepatitis and human immunodeficiency virus IHrv] infection).
Prevalence
In the United States, up to 90% of individuals hospitalized for medical care or surgery receive orders for seda tive, hypnotic, or anxiolytic medications during their hospital stay, and more than 15% of American adults use these medications (usually by prescription) during any 1 year. Mosl of these individuals take the medication as directed, w ithout evidence of misuse. Among the medications in thi s class, the benzodiazepines are the most widely used, with perhaps 10% of adults having t'"lken a benzo-diazepine for <'I t least 1 month during the p rior year. In both the Uni ted States and elsewhere, these drugs are usu ally prescribed by a p rimary care provider, and prescribed use of these medications is higher in women and increases with age. A 1996 national survey of drug use indicated that around 6% of individuals acknowledged using either sedatives or " tranquilizers" illicitly, including 0.3% who re porled illicit use of sedatives in the prior year and 0.1 % who reported use of sedatives in the prior month. The age group w ith the highest lifetime p revalence of sedatives (3%) or " tranquilizers" (6%) was 26-- to 34--year-olds, while those aged 18-25 were most likely to have used in the prior year. Because most surveys assessed patterns of use rather than disorders, it is nol known how many of those w ho used substances from this dass had symptoms that met criteria for Dependence or Abuse. A 1992 U.s. national survey reported a lifetime prevalence for Abuse or Dependence of less than 1%, including less than 0.1 % for 12 month prevalence.
Course
The more usual course involves young people in their teens or 20s who rna}' escalate their occasional use of sedatives, hypnotics, and anxiolytics to the point at which they
Substance-Related Disorders
d evelop problems that might qualify fo r a diagnosis of Dependence or Abuse. This pattern may be especially likely among individuals who ha ve other Substance Use Disorders (e.g., rela ted to alcohol, opioids, cocaine, amphetamine). An initial pattern of intenni llent use al parties can lead to daily use and high levels of tolerance. Once this occurs, an increasing level of interpersonal, work, and legal difficulties, as well as increasingly severe episodes of memory impairment and physiological withdrawal, C,1n be expected to ensue. The second and less frequently observed clinical course begins with an individual who originally obtai.ned the medication by prescription from a physician, usua lly for the treatment of anxiety. insomnia, or somatic complaints. Although the great majority o f those w ho are prescribed a medication from this class do not develop problems, a small p roportion d o. In these individua ls, as either tolerance or a need for higher doses of the medication develops, there is a gradual increase in the dose and frequency of self-administration. The person is likely to continue to justify use on the basis of the original symptoms of anxiety or insomnia, but substance-seeking behav ior becomes more p rominen t and the person may seek out multiple ph}'sicians to obtain sufficient supplies o f the medication. Tolerance can reach high levels, and Withdrawal (including seizures and Withdrawal Delirium) may occur. Other individuals at heightened risk migh t include those with Alcohol Dependence who may receive repeated p rescriptions in response to their complain ts of alcohol-related anxiety or . . msomrua.
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Sed ative-, Hypnotic-, or Anxiolytic-lnduced Disorders may present with symptoms (e.g., anxiety) that resemble primary mental disorders (e.g., Generalized Anxiety Disorder versus Sedative-, H ypnotic-, or Anxiolytic-Induced Anxiety Disorder, With Onset During Withdrawal). See p. 210 for a discussion o f this differential diagnosis. Seda tive, Hypnotic, or Anxiolytic Intoxication closely resembles Alcohol Intoxication, except for the smell of alcohol on the breath. In older persons, the clinical pichtre of intoxication can resemble a progressive dementia. l.n addition, the slurred speech, incoordina tion, and other associated feature s characteristic of Sedative, H ypnotic, or Anxiolytic Intoxica tion could be the result of a general medical condition (e.g., multiple sclerosis) or of a prior head tTauma (e.g., a subdural hematoma). Alcohol Withdrawal produces a synd rome very similar to that of Sedative, Hypnotic, or Anxiolytic Withdrawal. The anxiety, i..nsonmia, and autonomic nervous system h yperactivity that is a consequence of intoxication with other drugs (e.g., stimulants such as amphetamines or cocaine), that are consequences of physiological conditions (e.g., hyperthyroidism), or that are related to primary Anxiety Disorders (e.g., Panic Disorder or Generalized Anxiety Disorder) can resemble some aspects of Sedative, Hypnotic, or Anxiolytic Withdrawal. Sedative, Hypno tic, or Anxiolytic Intoxica tion and Withdrawal are distinguished from the other Sedative-, Hypnotic-, or Anxioly tic-Induced Disorders (e.g., Seda~ tive-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder, With Onset Drning Withdrawal) because the symptoms in these latter disorders are in excess of those usually
292.9 Sedative-, Hypnot ic-, or Anxiolyt ic-Related Disorder Not Othe rwise Specified
associated with Sedative, Hypnotic, or Anxiolytic Intoxication or Wi thdrawal and are severe enough to warrant independent clinical attention. It should be noted that there are ind ividuals who continue to take benzod iazepine medication according to a physician's direction for a legitimate medical indication over extended periods of time. Even if physiologically d ependent on the medication, many of these individuals do not develop symptoms that meet the criteria for Dependence because they are not preoccupied with obtaining the subs tance and its u se does not interfere with their perfonnance of usual social or occupational roles.
Polysubstance-Related Disorder
304.80
Polysubstance Dependence
This diagnosis is reserved fo r behavior during the same 12-month period in which the person was repeatedly using at least three groups of substances (not induding caffeine and nicotine), b u t no single s ubstance p redominated . Further, during this period, the Dependence criteria were met for s ubstances as a group but not for any specific substance. For example, a diagnosis o f Polysubstance Dependence would apply to an individual who, during the same 12-month period, missed. work because of his heavy use of alcohol, continued to use cocaine despite experiencing severe depressions after nights of heavy cons umption, and was repeatedly unable to s tay within hi s self-imposed limits regarding his use of codeine. In this ins tance, a lthough the problems associated w ith th e use of anyone s ubstance were not pervasive enough to jus tify a diagnosis of Dependence, his overall use of s ubstances significan tly impaired his functioning and thus warranted a diagnosis of Dependence on the subs tances as a group. Such a pattern might be observed, for example, in a setting where subs tance
294
use was highly prevalent but where the d rugs of choice changed frequently. For those situations in which there is a pa ttern of problems associated with multiple drugs and the criteria arc met for more than one s pecific Subs tance-Related Disorder (e.g., Cocaine Dependence, Alcohol Dependence, and Cannabis Dependence), each diagnosis should be made.
The O ther (or Unknown) Substance-Related Disord ers category is for classifying Substance-Related Disorders associated with substances not listed ahove. Examples of these substances, w hich are described in more detail below, incl ude anabolic steroids, nitrile inhalants (" poppers"), nitrous oxid e. over-the-counter and prescription med ications no t otherw ise covered by the 11 categories (e.g., cortisoL antihistamines, benztropine), and o ther substances that have psychoactive effects. In addition, this category may be used when the specific substance is unknown (e.g., an intoxication after taking a bottle of unlabeled pills) . Anaboli c steroids sometimes produce an initial sense of enhanced well-being (or even euphoria), which is replaced after repeated use b y lack of energy, irritability, and other forms of d ysphoria. Continued use of these substances may lead to more severe symptoms (e.g., depressive sym p tomatology) and general med ical condi tions (liver d isease). Ni trite inh alants ("poppers"-forms o f amyl, butyl, and isobuty l nitrite) produce an in toxication that is characterized by a feeling of fullness in the head, mild eup horia, a change in the perception o f time, relaxa tion of sm ooth muscles, and a possible increase in sexual feelings. In addition to possible compulsive use, these substances carry dangers of potential impairment of immune fun ctioning, irritation of the respiratory system, a d ecrease in the oxygen--carry ing capacity of the blood, and a toxic reaction that can include vomiting, severe headache, hypotension, and dizziness. Nitrous oxide ("laughing gas") causes rapid onset of an intoxication that is char.1Cterized by light-headedness and a floating sensation that d ears in a matter of minutes aft er ad ministration is stopped . There are reports of temporary but clinically relevant confusion and reversible paranoid states w hen nitrous oxide is used regu larly. Other substances that are capable of prod ucing mild intoxications include catnip, which can p roduce states similar to those observed w ith marijuana and w hich in high d oses is reported to result in LSD-type perceptions; betel nu t, wh ich is chewed in many cultures to p roduce a mild euphoria and floa ting sensation; and kava (a substance derived from the South Pacifi c pepper plant), which produces seda tion, incoordination, weight loss, mild forms of hepatitis, and lung abnormalities. In addition, ind ividuals can d evelop dependence and impairment through repea ted self-administration of over-the-counter and prescription drugs, includ ing cortisol, antiparkinsonian agents that have anticholinergic properties, and antihi stamines. A discussion of how to cod e med ication-rela ted disorders is found on p. 205. Texts and criteria sets have already been provided to d efine the generic aspects of Substance Dependence (p. 192), Substance Abuse (p. 198), Substance Intoxication
(p. 199), and Substance \,\'ithdrawal (p. 201) that are ap plicable across classes of sub stances. The Other (or Unknown) Substance-Induced Disorders are described in the sections o f the manual with d isorders with which they share phenomenology le.g., Other (or Unknown) Substance-Induced Mood Disorder is in cluded in the "Mood Disorders" section] . Lis ted below are the O ther (or Unknown) Substance Use Disorders and the Other (o r Unknown ) Substance-Ind uced Disorders.
Other (or Unkn own) Substance Dependen ce (see p. ] 92) Other (or Unknown) Subs tance Abuse (see p. 198)
292.12
292.84
292.89
292.89 292.89
292.9
Other (or Unknown) Substance Intoxicati on (see p . 199) Specify if: With PercepruaJ Disrurbances Other (or Unknown) Substance Withdrawal (see p. 201) SpecifiJ if: 'yVith Perceptual Dis turbances Other (or Un.known ) Substance-Induced Delirium (see p . 143) Other (or Unknown) Substance-Induced Persis ting Dementia (see p . 168) Other (or Unknown) Su bstance-Induced Persisting Amnesti c Di sord er (see p. 177) Other (or Unknown) Substance-Induced Ps ychoti c Disorder, With Delusions (see p . 338) Specify if: With Onset Du ring Intoxication/ With Onset During Withd rawal Other (o r Unknown) Substance-Induced Psychotic Di sorder, With Hallucinations (see p . 338) Specify if: With O nset During Intoxication / With Onset During Withdrawa l Other (or Unknown) Subs tance-Induced Mood Di sord er (see p. 405) Specify if: With Onset During Intoxication/ With Onset During Withdrawal Other (or Unknown) Substance- Induced A nxiety Diso rd er (see p. 479) Specify if: With Onset During Intoxication/ With Onset During ' ''' ithdrawal Other (or Unknown) Substance-Induced Sexual Dysfunction (see p. 562) Specify if: With Onset During Intoxication Other (or Unknown) Substance-Induced Sleep Disorder (see p. 655) Specify if: With Onset Dtuing Intoxication / \'\lith O nset During Withdrawal Other (or Unknown) Substance-Related Disorder Not Oth envise Specified
T he disorders in this section include Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Brief Psychotic Disorder, Shared Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, SubstanceInduced Psychotic Disorder, and Psychotic Disorder a t Otherwise Specified. These disorders have been g rouped together to facilitate the differential diagnosis of d isorders that include psychotic symptoms as a prominent aspect of their presentation. Other disorders that may present with psychotic symptoms as associated fea tures afe included elsewhere in the manual (e.g., Dementia of the Alzheimer' s Type and Substance-Induced Delirium in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section; Major Depressive Disorder, With Psychotic Features, in the "Mood Disorders" section). Despite the fact tha t these disorders are grouped together in this chapter, it should be understood that psychotic symptoms are not necessarily considered to be core or fundamental features of these disorders, nor d o the disorders in this section necessaril y have a common etiology. In fact, a number of studies suggest closer etiological associations between Schizophrenia and other disorders that, by definition, do not present with p sychotic symptoms (e.g., Schizotypal Personality Disorder). The term psychotic has historically received a number of different defin itions, none of wh ich has achieved universal acceptance. The narrowes t definition of psychotic is restricted to d elusions or promjnent hallucinations, with the hallucinations occurring in the absence of insight in to their pathological nature. A slightly less res trictive definition would also include prominen t hallucinations that the indiv idual realizes are hallucinatory experiences. Broader s till is a definition that also includes other p ositive symptoms o f Schizophrenia (i.e., disorganjzed speech, grossly disorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in earlier classifica tions (e.g., DSM-U and lCD-9) was probably far too inclusive and focused on the severity of functiona l impairment. In that context, a mental disorder was termed "psychotic" if it resul ted in "impairment that grossly interferes w ith the capacity to meet ordinary demands of life. " The tenn has also previously been defined as a "loss of ego boundaries" or a "gross impainnent in reaJj ty testing." In thi s manual, the term psycllOtic refers to the presence of certain symptoms. However, the specific cons tellation o f symptoms to w hich the term refers varies to some extent across the diagnostic categories. in Schizophrenia, Sch..izophreniform Disorder, Sch izoaffective Disorder, and Brief Psychotic Disorder, the term psycllotic refers to delusions, any prominent hallucinations, d isorganized sp eech, or disorganized or catatonic behavior. in Psychotic Disorder Due to a General Medical Condition and in
297
298
Subs tance-Induced Psychotic Disorder, psyclwtic re fe rs to d elu sio ns or only those hallucinations that a re not accompanied by insight. Finally, in Delusional Disorde r a nd
Shared Psychotic Disorder, psychotic is equivalent to delusional. The follow ing- disorders are included in this section:
Schizophrenia is a disorder that lasts for at least 6 months and includ es at leas t
1 month of acti ve-phase symptoms (Le., tw o [or more] of the following: delusions,
hatiucinations, disorganized speech, grossly diso rganized or catatonic behavior, nega tive symptoms). Definitio ns for the Schizophrenia 5ubt}' pes (Paranoid, Disorganized, Catatonic, Undiffe rentia ted, and Residual) are also included in this section. Schizophreniform Diso rde r is characterized by a symptoma tic presentation that is equivalent to Schizo phre nia e xcept for its duration (i.e., the d is turbance las ts fr om 110 6 months) and the absence of a requirement tha t there be a decline in fun ctioning. Schizoaffective Disorder is a disorder in w hich a mood episode and the activephase symptoms of Schizophrenia occur together a nd were preceded or a re followed by at leas t 2 wee ks of delu sions or hallucinations withou t prominent m ood symptoms. D elusional Disorder is cha racterized by a t least 1 month of nonbizarre delusio ns w itho ut other active-phase symptom s of Schizo phrenia . Brief Psycho lic Disorder is a disorder that lasts m a rc than 1 day a nd remits by 1 m o nth. Shared Psychotic Disorder is cha racterized by the presence of a delus io n in an individual who is influenced by someone else who has a longer-standing delusion w ith s imila r contcnt. In Psychotic Di sorder D ue to a General Medical Condition, the psychotic sym ptoms a re judged to be a direct physiological consequence of a ge neral medical cond ition . In Su bstance-Induced Psychotic Di sord er, the psychotic symptoms a re judged to be a direct physiological consequence of a drug of abuse, a m ed ication, or toxin exposure. Psychotic Disorder Not Othenvise Specified is incl uded for clas sify ing psychotic p resentations tha t do not meet the criteria for an y of the sp ecific Psycho tic Disorders defined in this sectio n or psychotic symptom a tology abo ut w hich there is inadequate or contradictory informa tion .
Schizophrenia
The essential feature s of Schizophrenia a re a mixture of cha racteris tic signs a nd symptoms (both positive and negative) tha t have been p resent for a s igni fi cant po rtion of time during a I-month period (or for a s horter time if s uccessfull y treated), w ith some s igns of the disorder persisting for at least 6 m onth:;! (Criteria A and C). These signs and symptoms a re associated with marked social or occu ational d 'sfunctio n (Criterio n B . e dis turbance is not be tter accounted (or b y Schizoaffective Disorder or a Mood Disord er With Psychotic Features and is not due +o..thc d irect J~hysio l og ical efff?:t ts of asubstanceor.a.general medical condi liQll (Crite ria D and E). In individuals with a previous diagnosis of A utis tic Disorde r (or anothe r Pe rvasive Develo pmen tal Disorder), the addi tional diagnOSiS of Schizophrenia is w arranted
Schizophrenia
299
and attention. No gi the diagnosis involves the recognition of a of signs and symptoms associated with impaired occupational or social fWlCtioning. Characteristic symptoms (Cri terion A) may be conceptualized as falling into two broad categories: positive and negative. The positive symptoms appear to reflect an excess or distortion of normal fun ctions, whereas the negative symptoms appear to reflect a diminution or loss of norm.a.l functions. The positive~ymE toms (Criteria AlM ) include distortions in thought content (delusions), perception (hallucinations), langu',!-ge and th~ugh t process (disorganized speech" and self-monit6ring-of-hehavor catatonic behavior). These positive symptoms mily commay iinum be rela ted to different underlying "disorganization dimension"
1~~~~~~:Z;:::~~
Delusions (Criterion A 1) are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their con tent may include a variety of themes (e.g., persecutory, referential, somatic, religious, or grandiose). Persecutory delusions arc most common; the person believes heor she is being tormented, followed, tricked, spied on, o r ridiculed. Referential delusions are also common; the person believes that certain gestures, comments, passages fTom books, newspapers, song lyrics, or other em'jronmental cues are specifically directed at him or her. The distinction between a delusion and a strongly held idea is sometimes difficult to m ake and d epends in part on the degree of conviction w ith which the belief is held des pite clear contradictory evidence regarding its veradry. , Although bizarre delusions are considered to be especially characteris tic of Schizophrenia, "b izarreness" may be difficult to judge, especially across d ifferent cu ltures. Delu sions are deemed b izarre if they are clearly implau sible and not understandable and do not derive fTom ordinary life experiences. An example of a bizarre delusion is a person 's belief that a st.ranger has removed his or her internal organs and has replaced them with someone else's organs without leaving any wowlds or scars. An example of a nonbizarre delusion is a person's false belief that he or she is under surveillance by U,e police. Delusions that express a loss of control over mind or body are generally considered to be bizarre; these include a person's belief tha t his or her thoughts have been taken away by some outside force ("th ought w ithdrawal "), tha t alien though ts have been pu t into his or her mind ("thought insertion"), or that his or her body o r actions are being acted on or manipulated by some outside force ("d elusions of control"). If the delusions are judged to be bizarre, only this single symptom is needed to sati sfy Criterion A for Schizophrenia. Hallucinations (Criterion A2) may occur in any sensory modality (e.g., auditory,
Sch izo p hre ni a and Other Psychot ic Disord e rs visual, olfac tory, gu statory, and tactile), but auditory hallucinations are by far the most common .. Auditory hallucinations are usually experienced as voices, w hether familiar or unfamiliar, tha t are perceived as distinct from the person's own thoughts~ The hallucinations must occur in the context of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the range of normal experience. Isolated experiences of hearing one's name called or experiences that lack the quality of an external percep t (e.g., a humming in one's head) should also not be considered as sym p tomatic of Schizophrenia or any other Psychotic Disord er. Hallucinations may be a normal pa rt of religious experience in certain cultu ral contexts. Certain typ es of aud itor}' hallucinations (Le., two or more voices con versing with one another or voices maintaining a running commentary on the person's thoughts o r behavior) have been considered to be particularly characteristic of Schizopluenia. If these types of hallucinations a re present, then only this single symptom is needed to sa tisfy Criterion A. Disorganized thinking (" formal though t disorder") has been argued by some to be the single most important feature of Schizophrenia. Because o f the difficulty inherent in d eveloping an objecti ve d efinit ion of " though t disorder," and because in a clinical setting inferences about thought are based p rimarily on the ind ividual's speech, the concept of d isorganized speech (Criterion A3) has been emphasized in the d efiniti on for Schizophrenia used in this manual. The speech o f ind ividuals with Schizophrenia m ay be d isorganized in a va riety of w ays. The person may "slip o ff the track" from one topic to another ("d erailment" or "loose associations"); answers to questions may be obliquely related or completely unrelated (" tangentiality"); and, rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its lingu istic d isorganization (" incoherence" or "word salad"). Because mildly disorganized speech is common and nonspeci fic, the symptom must be severe enough to substantia lly impair effective com munication. Less se\'ere disorganized thinking or speech may occur during the prod romal and residual period s of Schizophrenia (see Criterion C). Grossly disorganized behavior (Criterion A4) may manifest itself in a variety of ways, ranging from childlike silliness to unp red ictable agitation. Problems may be noted in any form of goal-directed behavior, leading to diffi cul ties in performing activities o f daily living such as preparing a meal or maintaining hygiene. The person m ay appear markedly disheveled , may d ress in an unusual manner (e.g., wea ring multiple overcoats, scarves, and gloves on a hot day), o r may display clearly inapprop riate sexual behavior (e.g., public masturbation) or unpred ictable and un triggered agitation (e.g., shou ting or swearing). Care should be taken not to apply this criterion too broadly. For example, a few instances of restless, angry, or agitated behavior should not be consid ered to be evidence of Schizophrenia, especia lly if the motivation is understandable. Cata tonic motor behaviors (Criterion A4) include a marked decrease in reactivity to the environment, sometimes reach ing an extreme degree o f complete unawareness (ca tatonic stupor), maintaining a rigid posture and resisting e ffort s to be m oved (cataton ic rigid ity ), active resistance to instructions or attempts to be moved (cata tonic nega tivism), the assumption o f inapp ropriate or bizarre postures (catatonic posturing), or purposeless and unstimulated excessive motor activity (catatonic excitement). Although catatonia has historically been associated with Schizophreni a, the
Schizophren ia
301
clin ician should keep in mind that ca tatonic symptoms are nonspecific and may occur in other mental disorders (see Mood Disorders With Ca tatonic Features, p. 417), in genera l medical conditions (see Catatonic Disorder Due to a General Medical Condition, p. 185), and Medication-Induced Movement Disorders (see NeurolepticInduced Parkinson is m, p. 792). The negative symptoms o f Schizophrenia (C riterion AS) account for a substantial degree of the morbidity associated with the disorder. Three negative symptomsaffective fl attening, alogia, and avolition-are included in the definition of Schizophrenia; o ther nega tive symptoms (e.g., anhedonia) are noted in the " Associated Features and Disorders" section below. Affective fl attening is especially common and is characterized by the person's face appearing immobile and unresponsi ve, with poor eye contact and reduced body language. Although a person with affective flattening may smile and warm up occasionally, his or her range of emotional expressiveness is clearly diminished most o f the time. It may be useful to observe the person in teracting with peers to determine whether affective fl attening is sufficien tly persisten t to meet the criterion. Alogia (poverty of speech) is man ifested by brie{. laconic, empty replies. The individual \\'ith alogia appears to ha ve a diminution of thoughts that is refl ected in decreased flu ency and p rod ucti vity of speech. This must be differentiated from an unw illingness to speak, a cHnica l judgment that may require observa tion over time and in a variety of si tuations. Avolition is cha racterized by an inability to initiate and persist in goal-directed activities. The person may sit for long periods of time and show little interest in participating in work o r soda l activities. Althuugh comm on in Schizophrenia, negative symptoms are difficult to evaluate because they occu r on a continuum with normality, arc relatively nonspecific, and may be due to a variety of other factors (including positive symptoms, med ica tion side effects, depreSSion, envirorunental understimulation, or demoraHLl tion). If a negative symptom is judged to be dearly attributable to any of these factors, then it should not be considered in making the diagnosis ofSchizopluenia. For example, the behav ior of an indiv idual who has the delusional beHef that he will be in danger if he leaves h is room or tal ks to anyone may mimic social isola tion, avolition, and alogia. Certain antipsychotic medications o ften p rod uce extrapyramidal side effects, such as bradykinesia, that may mimic affective flatt ening. The distinction between true negative symptoms and medication side effects often depend s on clinica l judgment concerning the type of antipsycllOtic medica tion, the effects of anticho linergic medications, and d osage adjustmen ts. The difficult distinction between nega tive symptoms and depressive symptoms may be informed by the other accompanying symptoms that are present and the fac t that individuals w ith symptoms of depression typically experience an intensely painful a ffect, where.1S those with Sch izophrenia h.we a diminution or emptiness o f affect. Finall y, chronic environmental underslimulation or demora liza tion may resu lt in learned apathy and avolilion. In establishing the presence of nega tive symptoms that are to be used in making the diagnosis of Schizophrenia, perhaps the best test is their persistence for a considerable period of time despite efforts directed at resolving each o f the potential causes d escribed above. It has been suggested that enduring negative symptoms tha t are no t attributilble to the secondary causes described above be referred to as "defi cit" symptoms. Criterion A fo r 5chizophrenia requires that at least h\'O of the five items be present concurrently for much of at least 1 month . However, if delusions are bizarre or haJlu-
Schizoph renia and Other Psychotic Disorders cinations involve "voices commenting" or "voices conversing," then the p resence of only one item is required . The presence of this relatively severe constella tion of signs and sympto ms is referred to as the "active phase." In those situations in which the active-phase symptoms remit within a month in response to treatment, Criterion A can still be considered to h ave been met if the clinician judges that the symptoms would have persisted for a month in the absence of effective treahnent. In children, evaluation of the characteristic symptoms should include due consideration of the presence of other disorders or developmental difficulties. For example, the disorganized s peech in a child with a Communication Disorder should notcoun! toward a diagnosis of Schizoph renia unless the degree of disorganization is significan tly greater than would be expected on the basis of the Communication Disorder alone. Schizophrenia involves d ysfunction in one or more major areas of functioning (e.g., interpersonal relations, work o r education, or self-care) (Criterion B). Typically, functioning is clearly below that which had been achieved before the onset of symptoms. U the disturbance begins in chi ld hood or adolescence, however, there may be a failure to achieve what would have been expected for the individual ra ther than a deterioration in functioning. Comparing the indh'idual w ith unaffected siblings may be helpful in making th is d etermination. Educational progress is frequen tly disrupted, and the individual may be unable to finish school. Many indh' iduals are unable to hold a job for su stained periods of time and are employed at a lower level than their parents ("downward drift"). The majo rity (60%-70%) of individu als with Schizophrenia do not marry, and most have relatively limited social contacts. The d ysfunction persists for a substantial period during the course of the disorder and does not appea r to be a direct result of any single feature. For example, if a woman quits her job beca use of the circumscribed delusion tha t her boss is trying to kill her, this alone is not sufficient evidence for this criterion unless there is a more pervasive pattern of d ifficulties (usually in multiple domains o f functioning). Som e signs of the disturbance must persist for a continu ous period of at least 6 mon ths (Criterion C). Ouring that time p eriod, there must be at least 1 month of symptoms (or less than 1 month if symptoms are successfull}' treated) that meet Criterion A of Schizophrenia (the active phase). Prodromal symptoms are often present prior to the active phase, and residual symptoms m ay follow it. Some prodromal and residual symptoms a re relatively mild or subthreshold forms of the positive symptoms specified in Criterion A. Individuals may express a var iety of unu sual or odd beliefs that are not of delusiona l proportions (e.g., ideas of reference or magical thinking); they may have unusual p erceptual experiences (e.g., sensing the presence of an unseen person or force in the absence of formed hallucinations); their speech may be generally understandable but digressive, vague, or overly abstract or concrete; and their behavio r may be peculiar but not grossly d isorganized (e.g., mumbling to themselves, collecting odd and apparently worthless objects). In addition to these p ositivelike symptoms, nega tive symptoms are particularly common in th e prodroma l and residual phases and can often be quite severe. Indi viduals who had been socially active may become withdrawn; they lose interest in previously pleasurable activities; they may beco me less talkative and inquisitive; and they may spend the bulk of their time in bed. Such negative symptoms are often the fi rst sign to the famil y that something is wrong; family members may ultimately report that they experienced the ind ivid ual as "gradually slipping away."
Sch izophre n ia
303
The following specifiers may be used to indicate the characteristic course of symptoms of Schizophrenia over time. These specifiers can be applied on ly a fter at least 1 year has elapsed since the initial onset of active-phase sympto ms. During this in itial I-year period, no cou rse specifiers can be g iven. Episodic With Intere pisod e Res idu al Symp toms. This specifier applies w hen the course is characterized by episodes in wh ich Cri terion A for Schizophrenia is m et and there are clin ically Significant residual symp toms between the episod es. With Prominent Nega tive Symptoms can be added if prominent negative symptoms are present during these resid ual period s. Episodic With No lnterepisode Resid ual Symptoms. TillS specifier applies when the course is characterized by episodes in w h ich Criterion A fo r Schizoph renia is met and there are no clinically significant residual symptoms between the episodes. Continuous. This specifier applies when characteristic synl p toms of Criterion A are met thro ughou t all (or most) of the course. With Prominent Negative Symptoms can be added if prominent negative sympto ms are also p resent. S ing le Epi sod e In Partial Remiss ion. This specifier applies w hen there has been a sing le episode in which Criterion A for Schizophrenia is met and some clinically Significant residual symptoms remain. With Prominent Nega tive Symp toms can be added if these residual symptoms includ e p rom inent negative symptoms. Singl e Episod e In Full Remission. This specifier ap plies w hen there has been a single episode in wh ich Criterion A for Schizophrenia h,l Sbeen met and no clinically signi.fi cant residual symptoms remain . Other or Unspeci fi ed Pattern . This specifier is used if another or an unspecified course pattern has been p resent.
Recording Procedures
The diagnostic code for Schizophrenia is selected based on the appropria te subtype: 295.30 for Paranoid Type, 295.10 for Disorganized Ty pe, 295.20 for Catatonic Type, 295.90 for Undifferentiated Typ e, and 295.60 for Residual Type. There are no fi fthdigit codes available for the course specifiers. In recording the name o f the disorder, the course specifiers are noted after the approp riate subtype (e.g., 295.30 Schizophrenia, Paranoid Type, Episodic With ln terepisode Residual Sym p toms, With Prom inent Nega tive Symptoms).
304
pression in the absence of an appropriate stimulus), which is one of the defining features of the Disorganized Type. Anhedonia is common and is manifested by a loss of interest or p leasure. Dysphoric mood may take the foml of depression, anxiety, or
anger. lllcre may be d is turbances in sleep pa ttern (e.g., s leeping during the day and nighttime activity or res llessness) . The individual may show a lack of interest in eating or may refuse food as a consequence of delusional beliefs. Often there are abnormalities of psych omotor activity (e.g., pacing, rocking, or apathetic immobility). Difficulty in concentration, attention, and memory is frequen tly evident. A majority of individuals with Schizophrenia have p oor insight regard ing the fa ct that they have a psychotic illness. Evidence suggests that poor insight is a manifestation o f the illness itsel f rather than a coping s trategy. It may be compa rable to the lack of awaren ess of neu rological d efi cits seen in s troke, temled (1II0sogllosia. Thi s symptom predis poses the individual to noncompliance w ith treatment and has been found to be predictive of higher relapse rates, increased number of invohmtary hospital ad missions, poorer psychosocial fun ctioning, and a p oorer course of illness. Depersonalization, derealization, and somatic con cerns may occur and sometimes reach delus ional proportions. Anxiety and phobias are common in Schizophrenia . Motor abnormalities (e.g ., grimacing, posturing, odd manneris ms, ritualis tic or stereotyped beha \!ior) are sometimes present. The life exp ectancy of individuals with Schizophrenia is shorter than that of the genera l p opulation for a variety of reasons. Suicide is an important factor, because approximately 10% of individuals with Schizophrenia commit s uicide--and beh\'een 20% and 40% make at least one attempt over the course of the illness. Although the risk remains high over the w hole lifes pan, specific ris k factors for s uicide include male gender, being under 45 years of age, depressive symptoms, feeling s of hop elessn ess, unemployment, and recent hospital discharge. Suicide risk is also elevated during p ostpsychotic periods . Males successfully complete suicide more often than females, but bo th groups are at increased ris k relati ve to the general p opula tion . Many s tud ies ha ve rep orted tha t subgroups of ind ivid ual s diagnosed with Schizophrenia have a higher incidence of assa ultive a nd violent behavior. The major predictors of violent behavior are male gender, younger age, past history of violence, noncompliance w ith antipsychotic merucation, and excessive substance use. However, it should be noted that most individuals with Schizophrenia are not more d angerous to others than those in the general population . Rates of comorbidity with Subs tance-Related Disorders are high . Nicotine Dependence is especially high, w ith es timates ranging from 80% to 90% of individuals w ith Schizophrenia being regular cigarette smokers. FurthemlOre, these individuals tend to sm oke heavily and to ch oose cigarettes with high nicotine content. ComorbidHy with Anxiety Disorders has als o been increasing ly recognized in Schizophrenia. In particular, rates of Obsessive-Compulsive Disorder and Panic Disorder are elevated in individuals w ith Schizophrenia relative to the general population. Schizotypal, Schizoid, or Paranoid Personality Disorder may sometimes preced e the onset of Schizophrenia. Whether these Personality Disorders are simply prodromal to Schizo-
Schizophrenia
305 \
phrenia or whether they constitute a separa te earlier di sorder is not cl ea r. An increased risk of Schizopluenia has been found in association with prena tal and childhood factors (e.g., prenatal exposure to flu, prenatal exposure to fa mine, obstetric complications, central nervous system infection in early childhood). Associated laboratory findings. No laboratory findin gs have been identified that are diagnostic of Schizophrenia . However, a variety of measures from neuroimaging, neuropsychological, and neurophysiological studies have shown differences beh\'een groups of individuals with Schizophrenia and appropriately matched control subjects. In the structural neuroimaging literature, the most widely studied and most consistently replicated finding continues to be enlargement o f the lateral ventricles. Many studies have also demonstrated d ecreased brain tissue as evidenced by widened cortical sulci and decreased volumes of gray and w hite matter. However, there is ongoing controversy as to whether the apparent d ecrease in brain tissue is a focal as opposed to a more diffuse process. When examined by region, the temporal lobe has most consistently been found to be decreased in volume, while the frontal lobe is implicated less often. '''' ithin the temporal lobe, there is evidence of foca l abnormalities, with medial temporal structures (hippocampus, amygdala, and en torhinal cortex), as well as the superior temporal gyrus and planum temporale, most consistently found to be sma ller in volume. Decreased thalamic volume has also been observed in both individuals with Schizophrenia and their unaffected first-degree relatives, but fewer studies have looked at this. Another finding that has been consistently replicated is that of increased basal ganglia size, but there is increasing evidence that this may be an epiphenomenon of trea tment with t)' pica! neuroleptic medica tion . An increased incidence of large cavum septum peU ucidi has also been demonstra ted i.n individuals with Schizophrenia. This may have important pathophysiological implications, because it is suggestive of an early (i.e., prenata l) midline d evelopmental brain abnorma li ty, at least in a subgroup of individuals with Schizophrenia. In terms of functional brain imaging studies, hypofrontality (i.e., a relative d ecrease in cerebral blood fl ow, metabolism, or some other pro,,-")' for neural activity) con tinues to be the most consistently replicated finding. However, there is increasing recognition that functional abnormalities are unlikely to be limited to an}' one brain region, and m ost of the more recent studies suggest more w idespread abnormalities involving cortical-subcortical circuitry. Neuropsychological deficits are a consistent finding in groups of individuals Witll Schizophrenia. Deficits are evident across a range of cognitive abilities, including memory, psychomotor abilities, attention, and difficulty in changing response set. In ad d ition to the presence o f these deficits among chronically ill individ uals with Schizophrenia, there is increasing evidence that many of these deficits are found among individuaJs during their first psychotic episode and prior to treatment with antipsychotic medication, in individuals with Schizophrenia who are in clinical remission, as well as in unaffected first~degree relatives. Fo r these reasons, some of the neuropsychological deficits are thought to reflect more fundamental features of the illness and, perhaps, to revea l vulnerability fa ctors for Schizophrenia. These deficits are clinically meaningful in that they are related to the d egree of difficulty that some individuals with Schizophrenia have with activities of d aily living as well as the ability to acquire skills in psychosocial rehabilitation. Accordingly, the severi ty of neu-
306
ropsychological deficits is a relatively s trong predictor of social and vocational outcome. Several neurophysiological abnormalities have been demonstrated in groups of individuals w ith Schizophrenia. Among the most common are deficits in the perception and processing of sensory stimuli (e.g ., impairment in sensory gating), abnonnal smooth pursuit and saccadic eye movements, slowed reaction time, alterations in brain laterality, a nd abnomlalities in evoked potential electroencephalograms. Abnormal laboratory find ings may also be n oted as a complication either of Schizophrenia or of its treatment. Some individual s with Schizophrenia drink excessive ammmts of fluid ("water intoxication") and d evelop abnormalities in urine specific gravity or electrolyte imbalances. Elevated creatine phosphokinase (CPK) levels may resuit from Neuroleptic Malignant Syndrome (see p. 795).
As sociat e d ph ysica l e xamination findings and general medical conditions . Individuals wi th Schizophrenia are sometimes physicaIJy awkward and may display nemological "soft signs." such as left / right confusion, poor coordination, or mirroring. Some minor physical anomalies (e.g., highly arched palate, narrow- or wide-set eyes or subtle malformations of the ears) may be more conunon among individuals with Schizophrenia . Perhaps the most common associated physical findings are motor abnomlil lities. Most of these are likely to be related to side effects from treatment with anti psychotic medications. Motor abnormalities that are secondary to neuroleptic treatment include Neuroleptic-Induced Tardive Dyskinesia (see p. 803), Neuroleptic-Induced Parkinsonism (see p . 792), Nemoleptic-Induced Acute Akathisia (see p. 800), Neurolep tic-Induced Acute Dystonia (see p. 798), and Neuroleptic Malignant Syndrome (see p. 795). Spontaneous motor abnormalities resembling those that may be induced by neuroleptics (e.g., sniffing, tongue clucking, grunting) had been described in the preneurolepticera and are also still observed, although they may be difficult to distinguish from nemoleptic effects. Other physical findings may be rela ted to frequently associated disorders. For example, because Nicotine Dependence is so common in Schizophrenia, these individuals are more likely to develop cigaretterelated pathology (e.g ., emphysema and other pulmonary and cardiac problems).
Schizoph re n ia There is some evidence that clinicians may have a tendency to overd iagnose Schizophrenia in some ethnic g roups. Studies conducted in the United Kingd om and the United States su ggest that Schizophrenia may be diagnosed more o ft en in individuals who are African American and Asian American than in o ther racia l groups. It is not clea r, however, whether these find ings represent true d iffe rences among radal groups o r w hether they are the result of clinician bias or cu ltural insensitivity. Culhlral diffe rences have been noted in the presentation, course, and outcome o f Schizophrenia. Catatonic behavior has been reported as relatively uncommon among individuals with Schizophrenia in the United States bu t is more common in nonWestern countries. Individuals with Schizophrenia in developing nations tend to have a more acute course and a better ou tcome than do individ uals in industrialized nations. The onset o f Schi zophrenia typicaUy occurs betw een the la te teens and the mid3Os, with onset p rior to adolescence rare (although cases w ith age at onset of 5 or 6 years have been reported ). The essential feature s of the condition are the same in children, but it may be particularly d ifficult to make the diagnos is in this age gTOUp. In children, d elus ions and hallucinations may be less eIabor.lted than those observed in adu lts, and visua l hallucinations may be more common. Disorganized sp eech is observed in a number of disord ers with childhood onset (e.g., Communication Disorders, Pervasive Developmental Disorders), as is d isorganized beh avior (e.g., AttentionDeficit/ Hyperactivi ty Disorder, Stereotypic Movement Disorder). These symptoms should not be attributed to Schizophrenia w ithout d ue con sidera tion of these more common d isord ers of ch ildhood . Sch izophrenia ca n also begin later in life (e.g., after age 45 years). Late-onset ca ses tend to be si.mila.r to earlier-onset Sduzophrenia, although a nu mber of d iffe rences h ave been observed . For example, the p roportion of affected women is g reater, and individuals w ith late onset are mo re likely to ha ve been married than indiv iduals wi th an earlier age at onset, bu t they are nonetheless more sociaUy isolated and impaired w hen contrasted to the general pop ulation. Clinical factors such as the p ostmenopausal state, human leukocyte antigen subtypes, and cereb rovascular d isease are possible risk factors. The clinical presentation is more likely to include persecutory delusions and hallucina tions, and less likely to include disorgan ized and negative symptoms. Often the cou rse is characterized by a predominance of positive symptoms w ith preservation of affect and social fWlCtioning. The course is typically chronic, although individuals may be qu ite responsive to anti psychotic medications in lower d oses. Among those w ith the oldest age a t onset (i.e., over age 60 years), sensory d eficits (e.g., auditory and visual loss) occu r more commonly than in the general ad ult population, althou gh their specific role in pa thogenesis remains unknown. There is also evidence su ggesting that cognitive impainnen t accompan ies the clinical picture. However, the issu e of whether iden tifiable brain pathology d efines la te-onset illness remains unclear. Evid ence from a large body of literature demonstrates that Schizoph renia is expressed differently in men and women. The mod al age at onset for men is between 18 and 25 years, and that for women is between 25 an d the m id-30s. The age-at-onset d istribution is bimodal for women, wi th a second peak occurrin g later in life, bu t unimodal among men. Ap proximately 3%-10% of women have an age at onset afte r 40, whereas late onset is much less common in men. ""omen also h ave better premorbid functioning than men. \"' omen w ith Schizophrenia tend to express more affective
sympto matology, paranoid delusions, and hallucinations, whereas men tend to express more negative symptoms (flat affect, avolition, social withdrawal). Regarding the course of Schizophrenia, women have a better prognosis than men , as d efined by number of rehospitalizations and lengths of hospital stay, overall duration of illness, time to relapse, response to neuroleptics, and social and w ork fun ctioning. However, the gender advantage in these parameters appears to attenuate to some degree w ith age (i.e., short- to medium-term outcome is beller in women , but long-term outcome for women, esp ecially in the postmenopausal p eriod, becomes more like that for men). A slightly higher incidence of Schizophrenia has been observed in men than in women. Further, a number of s tudies have demonstrated gender differences in the genetic trans mission of Schi zophrenia . Rales of Schizophrenia among famil y m embers of women w ith Schizo phrenia are higher than those among family members of men w ith Schizophrenia, while relatives of men have a higher incidence of schizotypal and schizoid personality traits than do those o f w om en.
Preva lence
Schizophrenia has been observed worldwide. Prevalences among adults are often reported to be in the range of 0.5% to 1.5%. Annual incidences are most often in the range of 0.5 to 5.0 per 10,000. Incidence es timates beyond this range have been reported for some p opulation groups-for ins tance, a far higher incid ence for secondgeneration African Caribbeans living in the United Kingdom. Birth cohort s tudies suggest some geographic and histo rical variations in incid ence. For examp le, an elevated risk has been rep orted among urban-born individ uals compared wilh rural-born individuals, as well as a gmdually declining incidence for later-born birth cohorts.
Cou rse
The median age at onset fo r the fi rst psychotic episode of Schizophrenia is in the earl)' to mid-20s for men and in the late 20s fo r women . The onset may be abrupt or insidious, but the majority of individuals dis play some type of prodromal phase manifested by the slow and g radual development of a variety of signs and symptom s (e.g., social w ithdrawal, loss of interes t in school or work, deterioration in hygiene and grooming, unus ual behavior, outburs ts of anger). Family members may find this behavior difficult to interpret and assume that the person is "going through a phase." Eventually, however, the appearance o f some active-phase symptom marks the d isturbance as Schizophrenia. The age at onset may have both pathophysiological and prognostic significance. Individuals w ith an early age at onset are more often male and have a poorer premorbid adjus tment, lower educational achievement, more evidence o f structural brain abnormalities, more prominent nega tive signs and symptoms, more evidence of cognitive impairment as assessed w ith neuropsychological testing, and a w orse outcome. Conversely, individuals with a later onset are more often female, ha ve less evidence of structural b rain abnormalities or cognitive impairment, and dis play a better o utcome. Most studies of course and outcome in Schizophrenia s uggest that the course may be variable, w ith som e individuals disp laying exacerbations and remissions, w hereas
Sch izophrenia others remain chronically ill Beca use of variability in definition and ascertainment, an accurate summary of the long-term o utcome of Schizophrenia is not possible. Complete remission (Le., a return to fu ll premorbid functioning ) is probably not common in Ihis disorder. Of those who remain ill, some appear 10 have a relatively stable course, whereas others show a progressive worsening associated with severe disability. Early in the illness, negative symptoms may be prominent, appearing primarily as prodromal features. Subsequently, positive symptoms appear. Because these positive sympto ms are particularly responsive to treatment, they ty pically diminish, but in many individuals, negative symptoms persist beh\'een episodes of positive symplams. There is some suggestion that negative symptoms may become steadily more prominent in some indiv iduals during the course of the illness. Numerous studies ha\'e ind icated a group of factors that are associated with a better p rognosis. These include good premorbid adjustmen t, acute onset, later age at onset, absence of anosognosia (poor insight), being female, precipitating events, associated mood disturbance, treatment with antipsychotic medkation soon after the onset o f the illness, consistent medication compliance (i.e., early and consistent trea tment predicts better response to later treatment with antipsychotic medication), brief duration of activephase symptoms, good interepisocle functi Oning, minimal residual symptoms, absence of structural brain abnormalities, normal neurologkal function ing, a famil y history of Mood Disorder, and no family hislory o f Schizophrenia.
Familial Pattern
The first-degree biological relatives of individuals with Schizophrenia have a risk for Schizophren ia that is about 10 times g rea ter than that of the general population. Concordance rates fo r Schizophrenia are higher in monozygotic twins than in dizygotic twins. Adoption studies have shown that biological relatives of individuals with Schizophrenia have a substantially increased risk for Schizophrenia, w hereas adoptive relatives have no increased risk. Although much evidence suggests the importance of genetic factors in the etiology of Schizophrenia, the existence of a substantial discordance rate in monozygotic h"ins also indicates the importance o f environmental fa ctors. Some relatives of individuals with Schizophrenia may also have an increased risk for a group o f m ental disorders, termed the scllizopllrellin spectrllm. Although the exact boundaries of the spectnUIl remain unclear, family and adoption studies suggest that it probably includes Schizoaffective Disorder and Schizotypal Personality Disorder. Other psychotic di sorders and Paranoid, Schizoid, and Avoidant Personality Disorders may belong to the schizophrenia spectrum as well, but the evidence is more limited.
Differential Diagnosis
A wid e variety of general m edical conditions can present with psychotic symptoms. Psychotic Disorder Due to a General Medical Condition, a d eliri um, or a dementia is diagnosed w hen there is evidence from the history, physical examination, or laboratory tests that indicates that the delusions or hallucinations are the direct ph ysiological consequence of a general medical condition (e.g., Cushing's syndrome, brain tumor) (see p . 334). Substance-Induced Psychotic Disorder, Substance-Induced De-
310
lirium, and Substance-Induced Persis ting Demen tia are distinguish ed from Schizoplu en ia by the fac t thai a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologicaUy related to the d elusions or hallucinations (see p . 338). Many d ifferent types of Su bstance-Related Disorders may produce symptoms similar to those of Schizophrenia (e.g., s ustained amphetamine or cocaine use
may produce delusions or hallucinations; phencyclidine use may produce a mixture of positive and negative symptoms). Based on a variety of features that characterize
the course of Schizophrenia and Substance-Related Disorders, the clinician must determine w hether the psychotic sym p toms have been initiated and maintained by the substan ce use. Ideally, the clinician should attempt to observe the individual during a su stained p eriod (e.g., 4 weeks) of abstinence. However, because such prolonged periods of abstinence are often difficult to achieve, th e clinician may need to consider other evidence, such as whether the psychotic symptoms appear to be exacerba ted by the substance and to diminish when it has been discontinued, the relative severity of psychotic symptoms in relation to the amount and dura tion of substance use, and knowledge of the characteristic symptoms produced by a particular substance (e.g., amphetamines typ ically produce delusion s and stereotypies, but not affective blunting or prominent negative symptoms). Distinguishing Schizophrenia from Mood Disord er With Psych otic Features and Schizoaffec tive Disorder is made difficult by the fact that mood disturbance is common during the prodromal, active, and residual phases of Schizophrenia. If p sychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Di sorder \o\' ith Psychotic Fea tures. In Schizoaffective Disorder, there must be a m ood episod e that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial po rtion o f the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia either have a d uration that is brief in relation to the total duration of the disturbance, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode. When mood symptoms that meet full criteria for a mood episode are superimposed on Schizophrenia and are of particular clinical significance, an additional diagnosis of Depressive Disorder N ot Othenvi se Specified or Bipolar Disorder Not Othenvise Specified may be given. Schizophrenia, Catatonic Type, may be difficul t to distinguish from a Mood Disorder With Catatonic Features. By d efini tion, Schizophrenia differs from Sch izophreniform Disorder on the basis of duration. Schizophrenia involves the p resence of symptoms (including prodromal or residual symptoms) for a t least 6 months, whereas the total duration o f symptoms in Schizophren iform Disorder must be at least 1 month but less than 6 months. Schizophrenifonn Disorder also does not require a d ecline in functioning. Brief Psychotic Disorder is defined by the presence of delusions, hallucinations, disorganized speech, or g rossly disorganized or cata tonic behavior lasting for at least 1 day but for less than 1 month . The differential diagnosis beh\'een Schizophrenia and Delusion al Di sorder Tests on the na ture of the delusions (nonbizarre in Delusional Disorder) and the absence of o ther characteristic symptoms of Schizophrenia (e.g., hallucinations, disorganized speech or behavior, or prominent negative symptoms). Delusional Disorder may bP
Schizoph renia
311
particularly difficult to differentiate from the Paranoid Type of Schizophrenia, because this subtype does not include p rominent d isorganized speech, disorganized behavior, or fl at or inappropriate affect and is often associated w ith less decline in functioni ng than is characteristic of the o ther subtypes of Sch izophren ia . When poor psyd lOsocial functioning is present in Delusional Disorder, it arises directly from the delusional beliefs themselves. A d iagnosis of Psychotic Disorder Not Otherwise Specified may be made if insufficient information is available to choose between Schizophrenia and other Psychotic Disorders (e.g., Schizoaffective Disorder) or to determine whether the presenting symptoms are substance induced or are the result of a general medical condition. Such lU1certai nty is particularly likely to occur early in the course of the d isorder. Although Schizophrenia and Pervasive Developmental Disorders (e.g., Autistic Disorder) share disturbances in language, affect, and interpersonal rela tedness, Ihey can be distinguished in a number of ways. Pervasive Developmental Disorders are cha r,lcteristicaUy recognized during infancy or early childhood (usually before age 3 years), whereas such early onset is rare in Schizophrenia . Moreover, in Pervasive Developmental Disorders, there is an absence of prominent delusions and hallucinations; more pronounced abnorma lities in affect; and speech thai is absen t or minimal and characterized by stereotypies and abnormalities in prosody. Schizophrenia may occasionally develop in individuals w ith a Pervasive Developmental Disorder; a diagnosis of Schizophrenia is warranted in indi viduals w ith a p reexisting diagnosis of Autistic Disorder or another Pervasive Developmental Disord er only if prominent hallucinations or delusions have been present for at least a mo nth . C hildhood-onset Schizophrenia must be disti nguished from chi ldhood presentations combining disorganized s peec h (from a Communication Disorder) and d isorganized behavior (from AHention-DeficitIHyperactivity Disorder). Sch izophrenia shares features (e.g., paranoid ideation, magical thinking, social avoidance, and vague and digressive speech) w ith and may be preceded by Schizotypa l, Sch izoid, or Paranoid Personality Disorder. An additional diagnosis of Schizophrenia is appropriate w hen the symptoms are severe enough to sa tisfy Criterion A of Schizophrenia. The preexisting Personality Disorder may be noted on Axis n followed by "Premorbid" in parentheses (e.g ., Schizotypal Personality Disord er (Premorbid )J.
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delusions
hallucinations disorganized speech (e.g . frequent derailment o r incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., aHective f lattening, alog ia, or avolition
Note: Only one Criterion A symptom is required if de lusions are bizarre or ha llucinations consist of a voice keeping up a run ning commentary on the person's behavior
or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a sign ificant portion of t he t ime since the onset of the disturbance, one or more major a reas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to t he onset (or when the onset is in childhood or adolescence, fa ilure to achieve expected level of interpersona l, academic, or occupational achievement).
C. Duration: Continuous signs o f the disturbance pe rsist for at least 6 months . Th is 6month period must include at least 1 month o f symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodroma l or residua l symptoms. During these prodromal or residual periods, the signs of the dist urbance may be manifested by o nly negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e .g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Diso rder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occu rred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duratio n has been brief relative to t he duration of the active and residual periods. E. Substance/general medical condition exclusion: The distu rbance is not due to the direct physiologica l effects of a substa nce (e.g., a drug of abuse, a medication) or a general medical condit ion . F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmenta l Disorder, the additiona l diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are a lso present for at least a mont h (or less if successfully treated).
Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initia l onset of active-phase symptoms):
Episodic With Interepisode Residual Symptoms (episodes are defined by the reemergence of prominent psychot ic symptoms); also specify if: With Prominent Negative Symptoms Episodic With No Interepisode Residual Symptoms Continuous (prominent psychotic sympt oms a re p resent throughout the period of obse rvation); also specify if: With Prominent Negative Symptoms
295.30
Paranoid Type
Schizophrenia Subtypes
The sub types of Schizophrenia are defined by the predominant symptomatology at
the time of evaluation. Although the prognostic and treatment implications of the subtypes are variable, the Paranoid and Disorganized Types tend to be the least and most severe, respectively. The d iagnosis of a particular subtype is based on the clinicill picture that occasioned the most recent evaluation or admission to clinical care and may therefore change over time. Not inhequently, the presentation may include symptoms that are characteristic of more than one subtype. The choice among suir types depends on the fo llowing algorithm: Catatonic Type is assigned whenever prominen t catatonic sym ptoms are present (regardless of the presence of other symplams); Di sorganized Type is assigned w henever disorganized speech and behavior and flat or inappropriate a ffect are prominent (tutl ess Catatonic Type is a lso present); Paranoid Type is assigned w henever there is a preoccupation w ith delusions or frequent hallucinations are prominent (unless the Cata tonic or Disorganized Type is present). Undifferentiated Type is a residual category d escribing presentations that include prominent active-phase symptoms not meeting criteria for the Catatonic, Disorganized, or Paranoid Type; and Residual Type is fo r presentations in which there is continuing evidence of the disturbance, but the criteria for the active-phase symptoms are no longer met. Because of the limited va lue of the schizophrenia subtypes in clinical and research settings (e.g., prediction of course, treatment response, correlates of illness), alternative subtyping schemes are being actively investiga ted. The alternative with the most empirical support to date proposes that three dimensions of psychopathology (psychotic, d isorganized, and negative) may come together in different ways among individ uals with Schizophrenia. This dimensiona l al ternative is d escribed in Appendix B
(p.765).
295.30
Paranoid Type
TIle essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusion s or auditory hallucinations in the context of a relative p reservation of cognitive functioning and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized speech, fl at or inappropriate affect, ca tatonic or disorganized behavior) are not prominen t. Delusions are typicaUy persecutory or grandiose, or both, but delusions w ith other themes (e.g., jea lousy, religiosity, or somatization) may also occur. The delusions may be multiple, but a re usuallyorganized around a coherent theme. Hallucinations are also typicaUy related to the content of
314
the delus ional theme. Associated features include ano ie!y, an ger, aloofness, and arx gumentativeness. The individual may have a s uperior and pa tronizing manner and either a s tilted, for mal q ualHy or extreme intens ity in interpersonal interactions. The persecutory themes may predispose the individual to s uicidal behavior, and the combination of persecutory and grandiose delusions with anger may predispose the individua l to violence. Onset tends to be later in life than the other types of Schizophrenia, and the distinguishing characteristics may be more s table over time . These individuals usually show little or no impairment on neuropsychologic.11 or other cognitive tes ting. Some evidence s uggests that the prognos is for the Paranoid Type may be consi derably better than for the other types of Schizoph renia, particu lMly with regard to occu pational functioning and ca pacity for independent living.
type of Schizoph renia in which the following crit eria are met:
None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate aHect.
295.10
Disorganized Type
The essential features of th e Disorganized Type of Schizophrenia are d isorganized speech, disorganized behavior, and fla t or inappropria te aHect. nle disorganized speech m ay be accompanied by silliness and laughter Utat are not closely related to the content of the speech . TIle behavioral disorgan iza tion (i.e., lack of goal orientation) may lead to severe d isruption in the abili ty to perform activities of daily living (e.g., showering, d ressing, or p re pari.ng meals). C riteria for the Catatonic Typ e of Schizophrenia Me not met, and delusions or hallucinations, if present, are fragmenta ry and not organized into a coherent theme. Associated features include grimacing, malUlerisms, and other oddities o f behavior. Impaired performance may be noted on a variety of neuropsycholOgica l and cogniti ve tests. This s ubtype is also usually associated with poor premorbid personality, carly and insidious onset, and a continuous course w ithou t significant remissions. Hjs lorically, and in other classification systems, this typ e is termed Ilebepilrellic.
295.20
Catatonic Type
315
295 .20
Catatoni c Type
The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negati vism , mutism, p eculiarities of voluntary movement, echolalia, or echopraxia. Motoric immobility may be manifested by catalepsy (waxy flexibility) or stupor. The excessive motor activity is apparently purposeless and is not influenced b}1 external stimuli. There may be extreme negativism that is manifested by the maintenance of a rigid postu.re against attempts to be moved or resistance to all instructions. Pecu liarities of voluntary movement are manifested by the voluntary assumption of inappropriate or bizarre postures or by prominent grimacing. Echola lia is the pathological, parrotlike, and apparently senseless repetition of a word or phrase just spoken by an o ther person. Echopraxia is the repetitive imitation of the movements of another person. Additional featu res include stereotypies, mannerisms, and automatic obedience or mimicry . During severe catatonic stupor or excitement, the person may need careful supervision to avoid self-harm or harming others. There are potential risks from maln utrition, exhaustion, hyperpyrexia, or self-inflicted injury. To diagnose this SUbtype, the individual's p resentation must first meet the full criteria for Schizophrenia and not be better accounted for b y another e tiology: substance induced (e.g., Neuroleptic-Induced Parkinsonism, see p. 792), ,1 general medical condition (see p. 185), or a Manic or ~'I ajor Depressive Episode (see p. 417).
nal sti muli) (3) extreme negativism (an apparently motiveless resistance to all instructions o r ma intenance of a rigid posture against attempts to be moved) or mutism (4) peculiarities of vol untary movement as evidenced by posturing (volunta ry assumpt ion of inappropri ate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent gri macing (5) echolalia or echopraxia
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Undifferentiated Type
The essential feature of the Undifferentiated Type of Schizophrenia is the presence of sympto ms that meet Criterion A of Schizophrenia but that do not meet criteria for the Paranoid, Disorganized, o r Catatonic Typ e.
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Residual Type
The Residual Type of Schizophrenia should be used when there has been at least one episode of Schizophrenia, but the curren t clinical picture is without prominent positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech or behavior). There is continuing evidence of the disturbance as indicated by the presence of negative symptoms (e.g., flat a ffect, poverty of speedl, or avolition) or two or more attenuated positive symptoms (e.g . eccentric behav ior, mildl y disorganized speech, or odd beliefs). If delusions or hallucinations are present, they are not prominent and are not accompanied by strong affect. The course of the Resid ual Type may be time limited and represent a transition between a full-bl own episode and complete remission. However, it may also be continuously present for many years, with or without acute exacerbations.
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disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g ., odd beliefs, unusual perceptual experiences).
Specif iers
The following specifiers for Schizophreniform Disorder may be used to indicate the presence or absence of features that may be associa ted with a better prognosis: With Good Prognostic Features. This specifier is used if at least h\'o of the following features are present: onset of prominen t p sychotic symptoms within 4 weeks of the firs t noticeable change in usual behavior or functioning, confusion or perplexity at the height of the psychotic episode, good premorbid social and occupational fun ctioning, and absence of blunted o r nat affect. Without Good Prognostic Features. This specifier is used if two o r more of the above features have not been present.
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Prevalence
Available evidence suggests variations in incidence across sociocultural settings. In the United Sta tes and other developed countries, the incidence is low, possibly fivefold less than that of Schizophrenia . In developing countries, the incidence is substantially higher, especially for the subtyp e "With Good Prognostic Features"; in some of these settings Schizophrenifoml Disorder may be as conunon as Schizophrenia.
Course
There is little available information on the course of Schizoph reniform Disorder. Approximately one-third of individuals with an initial diagnosis of Schizophreniform Disorder (provisional) recover within the 6-month period and receive Schizophreniform Disorder as their final diagnosis. Of the remaining h vo-thirds, the majority will progress to the diagnosis of Schizophrenia or Schizoaffective Disorder.
Familial Pattern
Few family studies have focused on Schizophreniform Disorder. Available evidence suggests that relatives of individuals with Schizophrenifo ml Disorder have an increased risk for Schizophrenia.
Differential Diagnosis
Because the d iagnostic criteria for Schizophrenia and Schizophreniform Disorder differ primarily in temlS of duration of illness, the discussion of the differential diagnosis of Schizophrenia (p. 309) also applies toSchizophreniform Disorder. Schizophreni form Disorder differs from Brief Psychotic Disorder, which has a duration of less than 1 month.
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Schizoaffective Disorder
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B. An episode of t he disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without
waiting for recovery, it should be qualified as "Provisional.")
Specify if :
Without Good Prognostic Features With Good Prognostic Features: as evidenced by two (or more) of the following: (1) onset of prominent p'>Ychot ic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning (2) confusion or perplexity at the height of the psychotic episode (3) good pre morbid socia l and occupationa l f unctioning (4) absence of blunted or f lat affect
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Diag nostic Feat ures
5chizoaffective Disorder
The essential feature of Schizoaffecti ve Disorder is an uninterrupted. period of illness during which, at some time, there is a Major Depressive, Manic, or Mixed Episode concurrent with symptoms tha t meet Criterion A for Schizophrenia (Criterion A). In addition, during the sa me period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (Criterion B). Finally, the mood symptoms are present for a substantial portion of the tota l duration of the illness (Criterion C). The symptoms must not be due to the direct physiological effects of a s ubstance (e.g., cocaine) or a general medical condition (e.g., hyp erthyroidism or temporal lobe epilepsy) (Criterion D). To meet criteria for Schizoilffective Disorder, the essential feannes must occur within a single uninterrupted period of illness. The phrase "period of illness" as used here refers to a time period during which the individua l continues to d isplay active or residual symptoms of psychotic illness. For some individuals, this period of illness may last for years or even decades. A period of illness is considered to have ended when the individual has completely reeov ered for a significant inten'al of time and no longer demonstrates any significant symptoms of the d isorder. The phase of the illness with concurrent mood and p sychotic symptoms is characterized by the full criteria being met for both the active pha se of Schizophrenia (Le., Criterion A) (see p. 298) and for a Major Dep ressive Episode (p. 349), a Manic Episode (p. 357), or a Mixed Episode (p. 362). The duration of the Major Depressive Episode must be at least 2 weeks; the duration of the Manic or Mixed. Epi sode must be at least 1 week. Because the psychotic symptoms must have a total duration of at least 1 month to meet Criterion A for Sch.izophrenia, the minimum duration of a schizoaffective
Schizophrenia and Other Psychotic Disorders episode is also 1 month. An essential feature of a Major Depressive Episode is the presence of ei ther depressed mood or markedly diminished interest or pleasure. Because loss of interest or pleasure is so common in non affective Psychotic Disorders, to meet Criterion A for Schizoaffective Disorder the Major Depressive Episode must include pervasive d epressed mood (i.e., the presence of markedly diminished interest or pleasure is not sufficient). The phase of the illness w ith psychotic symptoms alone is characterized by delusions or hallucinations that last at least 2 weeks. Although some mood symptoms may be present during this phase, they are not prominent. This d e tennination can be difficult and may require longitudinal observation and multiple sources of information. The symptoms of Schizoaffective Disorder may occur in a variety of temporal patterns. The following is a typical pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for 2 months before the onset of a prominent Major Depressive Episode. The psychotic symptoms and the full Major Depressive Episode are then present for 3 months. Then, the person recovers completely from the Major Depressive Episode, but the psychotic symptoms persist for another month before they too disappear. During this period of illness, the individual's symptoms concurrently met criteria for a Major Depressive Episode and Criterion A for Schizophrenia, and, during this same period of illness, a uditory hallucinations and delusions were present both before and after the depressive phase. The total period of illness lasted for about 6 months, with psychotic symptoms alone present during the initial 2 months, both depressive and psychotic symptoms present during the next 3 months, and psychotic symptoms alone present during the last month. In this instance, the duration of the depressive episode was not brief relative to the total duration of the psychotic disturbance, and thus the presentation qualifies for a diagnosis of Schizoaffective Disorder. Criterion C for Schizoaffective Disorder specifies that mood symptoms that meet criteria for a mood episode must be present for a substantial portion of the entire period of illness. If the mood symptoms are present for only a relatively brief period of time, the diagnos is is Schizophrenia, not Schizoaffective Disorder. In e valuating this criterion, the clinician should determine the proportion of time during the continuous period of psychotic illness (i.e., both active and residual symptoms) in which there were Significant mood symptoms accompanying the psychotic symptoms. The operationalization of what is meant by "a substantial portion of time" requires clinical judgment. For example, an individual w ith a 4-year history of active and residual symptoms of Schizophrenia develops a superimposed Major Depressive Episode thai lasts for 5 weeks during which the psychotic symptoms persis t. This presentation would not meet the criterion for "a s ubstantial portion of the total duration" because the symptoms that meet criteria for a mood episode occurred for only 5 weeks out of a total of4 years of disturbance. The diagnosis in this example remains Schizophrenia with the additional diagnOSiS of Depressive Disorder Not Otherwise Specified to indicate the superimposed Major Depressive Episode.
Subtypes
Two subtypes of Schizoaffective Dis order may be noted based on the mood component of the disorder:
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Bi polar Typ e. This subtype applies if a Manic Episode or Mixed Episode is part of the presentation. Major Depressive Episodes may also occur. Depressive Type. This subtype applies if only Major Depressive Episod es are part of the presentation .
Preva lence
Detailed informa tion is lacking, but Schizoaffective Disorder appears to be less common than Schizophrenia.
Cou rse
The ty pical age at onset of Schizoaffective Disorder is early adulthood, aJthough onset can occur anywhere from adolescence to late in life. The prognosis for Schizoaffecti ve Disorder is somewhat better than the prognosis for Schizoph renia, but considerab ly worse than the prognosis for Mood Disorders. Substantial occupationa l and social d ysfunction are coounon . The presence of precipitating events or s tressors is associated with a better prognosis. The outcome for Schizoaffective Disorder, Bipolar Type, may be better than th at for Schizoaffective Disorder, Depressive Type.
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Familia l Pattern
There is substantial evidence that there is an increased risk for Schizophrenia in firstdegree biological relatives of individuals with Schizoaffective Disorder. Most studies also show tha t relatives of individuals w ith Schizoaffective Disorder are at increased
Differential Diagnosis
General medical conditions and substance use can present with a combina tion of p sychotic and mood symptoms. Psychotic Disorder Due to a General Medical Condition, a delirium, or a dementia is diagnosed w hen there is evidence from the history, physical examination, or labora tory tests indica ting that the symptoms are the direct physiologica l consequence of a s pecific general medical condition (see p . 334). Subs tance-Induced Psychoti c Diso rder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the symptoms (see p. 338). Distinguishing Schizoaffective Disorder from Schizophrenia and from Mood Disorder With Psychotic Features is often difficult. In Schizoaffective Disorder, there mus t be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duralion of the d is turbance, and delusions or hallucinations m ust be present for at least 2 weeks in the absence of prominenl mood symptoms. In contrast, mood symptoms in Schizophrenia either have a duration that is brief relative to the total duration of the dishubance, occur only during the p rodromal or residu al phases, or do not meet full criteria fo r a mood episode. If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder With Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia (e.g., difficulty sleeping because o f disturbing auditory hallucinations, weight loss because food is considered poisoned, difficulty concentrating because of psychotic disorganization). Loss of interest o r pleasure is common in nonaffective Psychotic Disorders; therefore, to meet Cri terion A for Schizoaffec tive Disorder, the Major Depressive Episode must include pervasive depressed mood . Because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia (e.g., a diagnosis of Schi zoa ffecti ve Disorder for a severe and prominent Major Depressive Episode lasting 3 months during the first 6 months of a chronic psychotic illness would be changed to Schizophrenia if active psychotic or prominent residual symptoms persist over several years w ithout a reClurence of another mood episode) . The diagnosis may also change for different episodes of illness separated by a period of recovery. For example, an individual may have an episode of psychotic symptoms that meet Criterion A for Schizophrenia during a Major Depressive Episode, recover full y from this episode, a nd then later develop 6 weeks of delusions and hallucinations without prominent mood symptoms. The diagnosis in this instance would not be SchizoaHective
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Disorder because the p eriod of delusions and hallucinations was not continuous with the initial period of disturbance. In stead, the appropriate diagnoses for the first episode would be Mood Disorder With Psychotic Features, In Full Remission, and Scltizophreniform Disorder (provisional) for the current episode. Mood disturbances, especially depression, commonly develop during the course of Delusional Disorder. However, such presentations do not meet criteria for Schizoaffective Disorder because the p sychotic symptoms in Delusional Disorder are restricted to nonbizarre delusions and therefore do not meet Criterion A for SchizoaUective Disorder. If there is ins ufficient information concerning the relations hip between psychotiC and mood symptoms, Psychotic D isorder Not Othe rwise Specified may be the mos t appropriate diagnosis.
of the total duration of the active and residual periods of the illness.
O. The disturbance is not due to the direct physiological effects of a substance (e.g .. a
BipolarType: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes) Depressive Type: if the disturbance only includes Major Depressive Episodes
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Diagnosti c Features
The essential feature of Delusional Disorder is the presence of one or more non bizarre delusions tha t persist for at least 1 month (Criterion A). A diagnosis of Delusional Disorder is not given if the individual has ever had a symptom presentation that met Criterion A for Schizophrenia (Criterion B). Auditory or v isual hallucinations, if present, are not prominent. Tactile or olfactory hallucinations may be present (and prominent) if they are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation, or the perception that one emits a foul odor from a bod y orifice associated with d elusions of reference). Apart
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from the direct impact of the delusions, psychosocial functioning is not markedly impaired, and behavior is neither obviously odd nor bizarre (Criterion C). If mood episodes occur concurrently with the delusions, the total duration of these mood episodes is relatively brief compared to the total duration of the delusional p eriods (Criterion D). The delusions are not due to the direct physiological effects of a substance (e.g ., cocaine) or a general medical condition (e.g ., Alzheimer's disease, systemic lupus erythema tosus) (Criterion E). Although the determination of whether delusions are bizarre is considered to be especially important in distinguishing behveen Delusional Disorder and Schizophrenia, "bizarreness" m ay be difficult to judge, especially across different cultures. Delusions are deemed b izarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual's belief tha t a stranger has removed his or her internal organs and replaced them with someone else's organs w ithout leaving any wounds or scars). In contrast, nonbizarre delus ions involve situations that can conceivably occur in real life (e.g., being followed, poisoned, infected, loved at a distance, or deceived by one's spouse or lover). Psychosocial functioning is variable. Some individuaJs may appear to be relatively unimpaired in their interpersonal and occupational roles. In others, the impairment may be substantial and include low or absent occupational functioning and social isolation. ''''hen poor psychosocial fun ctioning is present in Delusional Disorder, it arises directly from the delusional beliefs themselves. For example, an individual who is convinced that he w ill be murdered by "Mafia hit men " may quit his job and refuse to leave his house except late at night and only when dressed in clothes quite different from his normal attire. All of this behavior is an understandable attemp t to prevent being identified and killed by his p resumed assassins. In contrast, poor functionin g in Schizophrenia may be due to both positive and negative symptoms (particularly avolition). Simi larly, a common characteristic of individuals w ith Delusional Disorder is the apparent normality of their behavior and appear.lnce when their delusional ideas are not being discussed or acted on. In general, social and marital functioning are more likely to be impaired than intellectual and occupational fun ctioning.
Subtypes
The type of Delusional Disorder may be specified based on the predom inant delusional theme: Erolomanic Type. This subtype applies when the centra l theme of the delusion is that another person is in love with the individual. The delusion often concerns idealized romantic love and spiritual union rather than sexual attraction. The person about w h om this conviction is held is usually of higher status (e.g., a famous person or a superior at work), but can be a complete stranger. Efforts to contact the object of the delusion (through telephone calls, letters, gifts, visits, and even surveillance and stalking) are common, aJthough OCC.1 sionally the person keeps the delu sion secret. Most individuals with this subtype in clinical samples are female; most individuaJs with this subtype in forens ic samples are male. Some individuals with this subtype, particularly males, come into conrrict with the law in their efforts to pursue the object of
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Delusional Disorder their delusion or in a misguided effort to " rescue" him or her from some imagined danger. Grandiose Type. This sUbtype applies when the centra l theme of the delusion is the conviction of having some great (but unrecognized ) talent or insight or having made some important discovery. Less commonly, the individual may have the d elusion of having a special relationship with a prominent person (e.g., an adviser to the president) or being a prominent person (in w hich case the actual person may be regarded as an impostor). Grandiose delusions may have a relig ious content (e.g., the person believes that he or she has a special message from a deity). Jealous Type. lhis subtype applies when the central theme of the person's delusion is that his or her spouse o r lover is unfaithful. lhis belief is arrived at without due cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed clothing or spots on the sheets), which are collected and used to justify the delusion. The individual with the delusion usually confron ts the spouse or lover and attempts to intervene in the imagined infidelit}r (e.g., restricting the spouse's autonom y, secretly following the spouse, investigating the imagined lover, attacking the spouse). Persecutory Type. This subtype applies when the central theme of the delusion involves the person's belief that he or she is being conspired against, cheated, spied on, followed , poisoned or d rugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights may be exaggera ted and become the focus of a d elusional system. The focus of the delusion is often on some injustice that must be remedied by legal action ("querulous paranoia"), and the affected person may engage in repeated attempts to obtain satisfacti on by appeal to the courts and other government agencies. individuals with persecutory delusions are often resentful and angry and may resort to v iolence against those they believe are hurting them. Somatic Type. This subtype applies when the central theme of the delusion involves bodily functions or sensations. Somatic d elusions can occur in several forms. Most common are the person's conviction that he or she emits a foul odor from the skin, mouth, rectum, or vagina; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are definitely (contra ry to all evidence) m isshapen or ugly; or that parts o f the body (e.g., the large intestine) are not functiOning. Mixed Type. This subtype applies when no one delusional theme predominates. Unspecified Type. This subtype applies when the dominant delusional belief calUlot be clearly detennined or is not d escribed in the specific types (e.g., referential delusions without a prominent persecutory or grandiose com ponent).
Schizophrenia and Other Psychotic Disorders ally consistent w ith the content of their delusional beliefs. Many individuals w ith Delusional Disorder develop irritable or d ysphoric mood, which can usually be understood as a reaction to their delusional beliefs. Especially with the Persecutory and Jealous Types, marked anger and violent behavior can occur. The individual may engage in litigious behavior, sometimes leading to hund reds of letters of protest to government and judidal officials and many court appearances. Legal difficulties can occur in Delusional Disorder, Jealous Type and Erotomanic Type. lndividuals with Delusional Disorder, Somatic Type, may be subject to unnecessary medica l tes ts and procedures. Hearing d efi Ciency, severe psychosocial slTessors (e.g., imm igration), and low socioeconomic s tatus may predispose an individual to the d evelopment of certain typ es of Delusional Disorder (e.g., Parano id Type). Major Depressive Epi+ sodes probab ly occur in indiv iduals with Delusional Disorder more frequently than in the gen eral p opulation . Delusional Disorder may be associated with ObsessiveCompulsive Disorder, Body Dysmorphic Disorder, and Paranoid, Schizoid , or Avoid+ ant Personality Disorders.
Prevalence
Delusional Disorder is relatively u ncommon in clinical settings, with most s tudies s uggesting tha t the disorder accounts for 1%- 2% of admissions to inpa tient mental health faciliti es. Precise information about the population prevalence of this disorder is lacking, but the best estimate is around 0.03%. Because of its usually late age a t onset, the Wetime morbidity risk may be between 0.05% and 0.1% .
Course
The age at onset of Delusional Disorder is variable, ranging from adolescence to latc in life. The Persecutory Type is the most common s ubtype. The course is quite variable. Especia lly in the Persecuto ry Type, the disorder may be chronic, although a waxing and wa ning of the preoccupation w ith the delusional beliefs oft en occms. In other cases, fu ll periods of remission may be followed by s ubsequ ent relapses. In yet other cases, the disorder remits w ithin a few months, often without subsequent relapse. Some evid ence sugges ts that the Jealou s Typ e may have a beller prognosis than the Persecutory Type. When the Persecutory Type is associated with a precipitating event o r s tressor, it may have a better prognosis.
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Delusional Disorder
Familial Pattern
Some studi es have found that Delusional Disorder is more common among relatives of individua ls with Schizophrenia than would be expected by chance, whereas other studies have found n o familial relationship beh\'een Delusional Disorder and Schizophrenia. There is limited evidence that Avoidant and Paranoid Personality Disorders may be especially common among fir st-degree biological relatives of individuals with Delusional Disorder.
Schizophren ia and Ot her Psycho t ic Diso rde rs etiology and cou rse. In Shared Psychotic Disord er, the delusions arise in the context of a close relationsh ip w ith ano ther person , are identical in form to the delusions of that other person, and d iminish or disap pear when the individual with Shared Psychotic Disorder is separa ted from the individual w ith the primary Psychotic Disorder. Brief Psychotic Diso rder is differentiated from Delusional Disorder by the fact tha t the d elusional sym p toms las t less than 1 month. A d iagnosis o f Psychotic Di sorder Not O then 'lise Sp eci fi ed may be made if insufficient info rmation is available to choose between Delusional Disorder and other Psychotic Disorders or to d etermine whether the presenting symptoms are subs tance induced or the result of a general medical condi tion . It may be difficu lt to d ifferentia te Hypochondriasis (esp ecially With Poor Insight) from Delusiona l Disorder. In Hypochondriasis, th e fea rs o f having a serious d isease or the concern that one has such a serious disease are held w ith less than delu sional intensity (Le., the individual can entertain the pOSSibility tha t the fea red disease is not p resent). Bod y Dysmorphic Disord er in volves a p reoccupation with some imagined defect in appearance. Many individuals w ith this disorder hold thei r beliefs w ith less than d elu sional intensity and recognize that their view of their appearance is d istorted. However, a significant prop ortion of individuals whose symp toms meet criteria for Body Dysmorphic Disorder hold their beliefs w ith delusional intensity. When criteri a for both d isorders are met, both Body Dysmorphic Disorder and Delusional Disord er, Soma tic Ty pe, may be d iagnosed. The boundary between ObsessiveCompulsive Disorder (especially W ith Poor In sigh t) and Delusional Disorder can sometimes be difficult to establish . The ab ility of ind ivid uals with ObsessiveComp ul sive Disorder to recognize that the obsessions or comp ulsions are excessive or unreasonable occurs on a con tinuum. In some ind ivid uals, reali ty tes ting may be los t, and the obsession may reach d elu sional proportions (e.g., the belief that one has caused the death of another person by having willed it). lf the obsessions develop into sus tained delusiona l beliefs that represent a major part of the cl inical picture, an additional diagnosis of Delusional Disord er may be appropriate. In con trast to Delusional Disorder, there are no clear-cut or persis ting d elusional beliefs in Paranoid Person ality Disorder. Whenever a person with a Delusional Disorder h as a preexisting Personality Disorder, the Personality Disorder should be listed on Axis II, followed by "Premorbid " in parentheses.
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edly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Specify type (the following types are assigned based on the predominant delusional
theme): Erotomanic Type: delusions that another person, usually of higher status, is in love with the ind ividual Grand iose Type: delusions of inflated worth, power, knowledge, identity, or special relat ionship to a deity or fa mous person Je alous Type: delusions that the individual's sexua l partner is unfait hful Pe rsecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way Somatic Type : delusions that the person has some physical defect or general medical condition Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates Uns pe cified Type
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Diag nostic Feat ures
The essential feature of Brief Psychotic Disorder is a dis turbance that involves the sudden onset of at least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), or grossly disorganized o r catatonic behavior (Criterion A). An episode of the dishlrbance lasts at leas t 1 day but less than 1 month, and the individual eventua lly has a full return to the premorbid level of fun ctioning (Criterion B). The dis turbance is not better accounted for by a Mood Disorder With Psychotic Feahues, by Sc.hizoaffective Disorder, or by Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a hallucinogen) or a general medical condition (e.g., subdural hematoma) (Criterion C).
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Specif ie rs
The fo llowing specifiers for Brief Psychotic Di sorder rna }' be noted based on the presence or absence of precipitating stressors:
With Marked Stressor(s). This s pecifier may be noted if the psychotic symptoms develop shortly after and apparently in res ponse to one or more events that, singly o r together, would be markedly stressful to almost anyone in sim-
ilar circumstances in that person's culture. This type of Brief Psychotic Disorder was called "brief reacti ve psychosis" in DSM-l1I-R. The precipitating event(s) may be any major s tress, such as the loss o f a loved one or the psychological trauma of combat. Delemlining whether a specific stressor was a precipitant or a consequence of the illness may sometimes be clinically difficult. In s uch instances, the decision will depend on rela ted fa ctors such as the temporal relationship between the stressor and the onset of the symptom s, ancil lary information from a spouse o r friend about level of flmctioning prior to the s tressor, and history of similar res ponses to s tressful events in the pas t. Witho ut Marked Stressor(s). This specifier may be noted if the p sychotic symptoms are not apparently in response to events that would be markedl}' stressful to almost anyone in similar circumstances in the person's culture. With Post partum Onset. This specifier may be noted if the onset of the psychotic symptoms is within 4 weeks pos tpartum .
Preva lence
Cases of Brief Psychotic Disorder are rarely seen in clinical settings in the United States and other developed countries. The incidence and prevalence of cases that do not come to clinica l attention are wlknown . However, psychotic disturbances that
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met the A and C criteria for Brief Psychotic Disorder but not the B cri terion (i.e., the duration of active sym p toms is 1-6 mo nths as opposed to remitting with in a month) are more common in developing countries than in d eveloped countries.
Course
Brief Psychotic Disorder may appear in adolescence or early adulthood, w ith the average age at onset being in the la te 20s or early 30s. By definition, a d iagnosis of Brief Psychotic Disorder requires a full remission of all symptoms and a return to the premorbid level of functioning within 1 month of the onset of the disturbance. In some individuals, the duration of psychotic symptoms may be quile brief (e.g., a few d ays).
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there is evidence that the symptoms are intentionally produced . When Malingering involves apparently psychotic symptoms, there is usually evidence that the illness
was feigned for an understandable goal. T certain individuals with Personality Disorders, psychosocial s tressors may pren cipitate brief periods of p sychotic symptoms. These are usually transient and do not warrant a separate diagnosis. If psychotic symptoms persist for at least 1 day, an ad-
(4) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a cu lturally sanctioned response pattern.
B. Duration of an episode of the dist urbance is at least 1 day but less than 1 month, with
With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after a nd apparently in response t o events that, singly or togethe r, would be markedly stressful to almort anyone in similar circumstances in the person's culture Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost a nyone in similar circumstances in the person's culture With Postpartum Onset: if onset within 4 weeks postpa rtum
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a Deux)
Diagnosti c Features
The essential feature of Shared Psychotic Disorder (Folie a Deux) is a delusion that develops in an individual who is involved in a close relationship with another person (sometimes termed the "inducer" or " the primary case") who already has a Psychotic Disorder with prominen t delusions (Criterion A). The indh'idual comes to share the d elusional beliefs of the primary case in whole or in part (Criterion B). The delusion is not better accounted for by another Psychotic Disorder (e.g., Schizoph renia) or a Mood Disorder With Psychotic Features and is no t due to the d irect physiological
a De ux)
effects of a substance (e.g., amphetamine) or a general medical cond ition (e.g., brain tumor) (Criterion C). Schizophrenia is p robably the most common d iagnosis of the primary case, although other diagnoses may include Delusional Disorder or Mood Disorder With Psychotic Feahtres. The conten t of the shared delusional beliefs may be dependent on the d iagnosis of the primary case and can include relatively bizarre delusions (e.g., that radiation is being transmitted into an apartment from a hostile fo reign power, causing indigestion and dia rrhea), mood-congruent d elusions (e.g., that the primary case w m soon receive a film contract for 52 million, allowing the fa mily to purcllase a m uch larger home w ith a swimming pool), or the nonbizarre delusions that are characteristic of Delusional Disorder (e.g., the FBI is tapping the fa mily telephone and trailing famil y members when they go o ut). Usually the primary case in Shared Psychotic Disorder is dominant in the relationship and gradually imposes the delusional system on the mo re passive and initially healthy second person. Ind ividuals w ho come to share d elusional beliefs are oHen related by blood or marriage and have lived together for a long time, sometimes in relative social isolation . If the relationship with the p rimary case is interru pted , the delusional beliefs of the other individual u.suaUy d iminish or disappear. Although m ost commonly seen in relationships of only two people, Shared Psychotic Disorder can occu r among a larger number of individual s, especially in fam.ily situations in w hich the parent is the primary case and the children, sometimes to vary ing degrees, adopt the parent's delusional beliefs. Individuals with th is disorder rarely seek treatment and usually are broug ht to clinical attention when the p rimary case receives treatment.
Prevalence
Little systematic information about the prevalence of Sha.red Psychotic Disorder is available. This disorder is rare in clinical settings, although it has been argued that some cases go unrecognized . Limited evidence suggests that Shared Psychotic Disorder is somewhat more common in women than in men.
Course
Little is known about the age at onset o f Shared Psycho tic Disorder, but it appears to be quite variable. Without intervention, the course is usually chronic, because this disorder most commonly occurs in relationships that are long-standing and resistant to change. With separation from the primary case, the individ ual's d elusional beliefs disappear, sometimes q uickly and sometimes quite slowly.
Differential Diagnosis
The diagnosis of Shared Psychotic Disorder is made only when the d elusion is not due to the d irect physiological effects of a substance or a general medical condition.
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Differential diagnosis is rarely a problem because the history of close association with the prima ry case and the similarity o f delusions between the two ind ividuals is unique to Shared PsydlOtic Disorder. In Schizophrenia, Delusional Disorder, Schizoaffective Disord er, and Mood Disorder With Psychotic Features, there is either no close relationship w ith a d om inant person who has a Psychotic Disorder and shares similar delusional beliefs or, if there is such a person, the psycho tic symptoms usually preced e the onset of any shared delusions. In rare cases, an ind ividual may present with what appears to be Shared Psychotic Disorder, but the delusions d o nol d isappear when the indiv idual is separa ted from the primary case. In such a sihliltion, il is p robably appropriate to consid er another Psychotic Disorder d iagnosis.
C. The disturbance is not better accounted for by another Psychotic Disorder (e.g., Schizophrenia) or a Mood Disorder W ith Psychotic Features and is not due to t he direct phySiological eff ects of a substance (e.g ., a drug of abuse, a medication) or a general medical condition.
335
natory phenomena. Ol factory hallu cinations, especially those involving the s mell of burning rubber or other unpleasant smells, are highl y s uggestive of temporal lobe epilepsy. Hallucination s may vary from s imple and unformed to highly complex and organized, depending on etiological fa ctors, environmental surroundings, nature and focus of the ins ult rendered to the central nen'ous system, and the reactive response to impairment. Psychotic Disorder Due to a General Medical Condition is generally not diagnosed if the individual maintains rea lity testing for the hallucination and appreciates that the perceptual experie nces result from the general medical COIldition. Delusions may express a variety of themes, including somalic, grandiose, religious, and, most commonly, persecutory. Religious delusions have been specifically associated in some cases with temporal lobe epilepsy. Individuals with right parietal brain lesions can develop a contralateral neglect syndrome in w hich they may disown parts of their body to a delusional extent. O n the whole, however, associations between delusions and particular general medical conditions appear to be less s pecific than is the case for hallucina tions. In determining whether the psychotic disturbance is due to a general medical condition, the clinician mus t firs t establish the presence of a general medica l cond ition. Further, the clinician mus t establish that the p sychotic d isturbance is etiologically related to the general medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. A lthough there are no infallible guidelines for determining whether the relationship between the pSycl10tiC disturbance and the general medical condition is etiologica l, several considerations provide some guidance in this area. One consideration is the p resence of a temporal association beh\'een the onset, exacerbation, or remission of the general medical condi tion and tha t of the psychotic disturbance. A second consideration is the presence of features that are atypical for a primar}' Psychotic Disorder (e.g., atypical age at onset or presence of visual or olfactory hallucina tions) . Evidence from the literature tha t suggests that the re can be a direct association beh\'een the general medical condition in question and the development of psychotic symptoms can provide a useful context in the assessment of a particular situation. In addition, the clinician mus t also judge that the disturbance is not better accounted for by a primary Psychotic Disorder, a Substance-Induced Psychotic Disorder, or another primary menial disorder (e.g., Adjustment Disorder). This dete rmination is explained in greater detail in the "Mental Diso rders Due to a General Medical Condition " section (p. 181).
Subtypes
One of the following subtypes may be lI sed to indicate the predominant symptom presentation. lfboth delusions and hallucinations are present, code whichever is predominan t: 293.81 With De lus ions. This s ubtype is used if delusions are the predominant symptom. 293.82 With Ha llucinations. This subtype is used if hallucinations are the predominant symptom .
336
Recording Procedures
In record ing the d iagnosis of Psychotic Disorder Due to a General Medical Condi tion, the clinician should first note the presence of the Psychotic Disorder, then the identified general medical condition judged to be causing the distur bance, and finally the appropriate specifier indicating the predominant symptom presentation on Axis I (e.g., Psychotic Disorder Due to Thyrotoxicosis, With Hallucinations). The diagnos tic code on Axis I is selec ted based on the subtype: 293.81 for Psychotic Disorder Due to a General Medical Condition, With Delusions, and 293.82 for Psychotic Disorder Due to a General Medical Condition, With Hallucinations. The ICD-9-CM code for the
general medical condition should also be noted on Axis III (e.g., 242.9 thyrotoxicosis). (See Appendix G for a list of ICO-9-CM diagnostic codes for selected general medical conditions.)
Preva lence
Prevalence rates for Psychotic Disorder Due to a General Medical Condition are difficu lt to estima te given the w ide variety of underlying medical etiologies. Research docs suggest that the synd rome is underd iagnosed in the general medical setting. Psychotic symptoms may be present in as many as 20% of individuals presenting with untreated endocrine disorders, 15% of those with systemic lupus erythematosus, and up to 40% or more o f individuals wi th lemporallobe epilepsy.
Course
Psychotic Disorder Due to a General Medical Condition may be a single transient state or it may be recurren t, cycling w ith exacerbations and remissions o f the underlying general medical condition. Although trea tment of the underlying general medical condition often results in a resolution o f the psychotic symptoms, this is not always the case, and psychotic symptoms may persist long after the causative medical event (e.g., Psychotic Disorder Secondar)' to Focal Brain Lnjury).
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Differential Diagnosis
Hallucinations and delusions commonly occur in the context o f a deliri um; however, a separa te diagnosis of Psychotic Disorder Due to a General Medica l Condition is not given if the disturbance occurs exclusively during the course of a d elirium. In contrast, a diagnosis of Psychotic Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the psychotic symptoms are a direct etiological consequence of the pathologica l process causing the dementia. Because of ICD-9-CM coding requiremen ts, an exception to this is when d elusions occur exclusively during the course of Vascular Demen tia. In this case, o nly a diagnosis of Vascular Dementia w ith the subtype With Delusions is given; a sepa rate diagnosis of Psychotic Disorder Due to a General Medical Condition is not made. If the presentation includes a mix of different types o f symptoms (e.g., psychotic and anxiety), the diagnosis is usually Psychotic Disorder Due to a General Medical Condition because in such situ ations pSydlOtic symptoms typically predominate in the cli.n.ical picture. If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin (e.g., LSD Intoxication, Alcohol Withdrawal), a Substance-Induced Psychotic Disorde r should be considered. It may be useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation. Symptoms that occur during or shortly after (i.e., within 4 weeks of) Substance Intoxication or Wi thdrawal or after medication use may be especially indicative of a Substance-Induced Psychotic Disorder, d epending on the character, duration, or amount of the substance used. If the clinician has ascertained that the disturbance is due to both a general medical cond ition and substance use, both diagnoses (i.e., Psychotic Disorder Due to a General Medical Condi tion and Substance-Induced Psychotic Diso rder) can be given. Psychotic Disorder Due to a General Medical Condition must be distinguished from a primary Psychotic Disorder (e.g., Schizophrenia, Delusional Disorder, Schizoaffective Disorder) or a primary Mood Disorder With Psychotic Features. In primary Psychotic Disorders and in primary Mood Disorders With Psychotic Features, nospecific and direct causative physiological mechanisms associated w ith a general medical condition can be demonstra ted. La te age at onset (e .g., the first appearance of delusions in an individual over age 35 years) and the absence of a personal or famil y history of Schizophrenia or Delusional Disorder suggest the need for a thorough assessmen t to rule out the diagnosis of Psychotic Disorder Due 10 a Genera l Medical Condition. Aud.ilory hallucinations that involve voices speaking co mplex sentences are more characteristic of Schizophrenia than of Psychotic Disorder Due to a General Medical Condition. Other ty pes of hallucinations (e.g., visual. olfactory) commonly signal a Psychotic Disorder Due to a General Medical Condition or a SubstanceInduced Psychotic Disord er. Psychotic Disorder N ot Oth envise Specified is diagnosed when the clinician cannot determine if the pSydlOtiC d isturbance is primary, substance induced, or due to a genera l medical condition. Hypnagogic and hypnopompic hallucinations may occur in ind ividua ls without a mental di so rder, but they occur on ly on faUing asleep or on awakening.
D. The disturbance does not occur excl usively during the course of a delirium.
Code based on predominant symptom:
.81 .82
With Delusions: if delusions are the predominant symptom With Hallucinations : if hallucinations are the predominant symptom
Coding note: Include the name of the general medical condition on Axis I, e.g., 293.81 Psychotic Disorder Due to Malignant lung Neoplasm, With Delusions; also code the general medica l condition on Axis III (see Appendix G for codes). Coding note: If delusions are part of Vascu lar Dementia, indicate the delusions by cod ing the appropriate subtype, e.g., 290.42 Vascular Dementia, With Delusions.
339
Disorders arise only in association with intoxication or w ithdrawal states but can persist for weeks, whereas primary Psychotic Disorders may precede the onset of substance use or may occur during times of sustained abstinence. Once initia ted, the psychotic symptoms may continue as long as the substance use continues. Another consideration is the presence of featu res that are atypical of a primary Psychotic Disorder (e.g., atypical age at onset or course). For example, the appearance of d elusions de novo in a person over age 35 years w ithout a known history of a primary Psychotic Disord er should alert the clin ician to the possibility of a Substance-Induced Psychotic Disorder. Even a prior history of a primary Psychotic Disorder does not rule out the possibility of a Substance-Induced Psychotic Disorder. It has been suggested that 9 out of 10 nonauditory hallucinations are the product of a Substance-Induced Psychotic Disorder or a Psychotic Disorder Due to a General Medical Condition. In contrast, factors that suggest that the psychotic symptoms are betler accounted for by a primary Psychotic Disorder include persistence of psychotic symptoms fo r a substantial period of time (Le., a mon th or more) after the end of Substance Intoxica tion or acute Substance Withdrawa l; the development o f symp toms that a re substantially in excess of what would be expected given the type or amount of the substance used or the duration o f use; or a history of prior recurrent primary Psychotic Disorders. Other causes of psychotic symptoms must be considered even in a person with Intoxication or Withdrawal, because substance use problems are not uncommon among persons with (presumabl},) non-substance-induced Psychotic Disorders.
Recording Procedure s
The name of the Substance-Induced Psychotic Disorder beg ins with the specific substance (e.g., cocaine, methylphenidate, dexamethasone) that is presumed to be causing the psychotic symptoms. The diagnostic code is selected from the listing of classes
Specific Substances
Psychotic Disorders can occur in association w ith intoxication w ith the following classes of substances: alcohol; amphetamine and related substances; cannabis; cocaine; hallucinogens; inhalants; opioid s (meperidine); phencyclidine and related substances; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Psychotic Disorders can occur in association w ith withdrawal from the following classes of substances: alcohol; sedatives, hypnotics, and anxiolytics; and other or unknown substances. The initiation o f the d isorder may vary conSiderably with the substance. For example, smoking a high dose of cocaine may p roduce psychosis within minutes, whereas days or weeks of hig h-dose aJeohol o r sedative use may be required to produce psychosis. Hallucinations may occur in any modality, but, in the absence of delirium, they are usually auditory. Alcohol-Induced Psychotic Disorder, With Hallucinations, usually occurs only after prolonged , heavy ingestion of alcohol in people who apparently have Alcohol Dependence. The a uditory ha llucinations are usually voices. The Psychotic Disorders induced by intoxication with amphetamine and cocaine share similar clinical features. Persecutory d elusions may rapidly develop shortly after use of ampheta mine or a similarly acting sympathomimetic. Distortion of body image and misperception of people's faces may occur. The hallucination of bugs or vermin crawling in or under the skin (formication) can lead to scratching and extensive skin excoriations. Cannabis-Induced Psychotic Disorder may develop shortly after high-dose cannabis use and usually in volves persecutory delusions. The disorder is apparently rare. Marked anxiety, emotional lability, depersonaliza tion, and subsequent amnesia for the episode can occur. The disorder usually remits within a d ay, but in some cases may persist for a few days. Substance-Induced Psychotic Disord ers may a t times not resolve promptly when
Differential Diagnosis
A diagnosis ofSubstance-lnduced Psychotic Disorder should be made instead of a diagnosis o f Substance Intoxication or Substance Withdrawal only when the psychotic symptoms are judged to be in excess of those usuaUy associa ted with the intoxication or withdrawal syndrome and when the symptoms ace s ufficiently severe to warrant independent clinical attention. Individuals intoxicated w ith s timulants, cannabis, the opioid meperidine, or phencyclidine, or those withdrawing from alcohol or sedatives, may exp erience altered perceptions (scintillating lights, sounds, visual illusions) that they recognize as deug effects. If reality tes ting for these experiences remains intact (i.e., the person recognizes that the perception is subs tance induced and neither believes in nor acts on it), th e d iagnosis is not Subs tance-Induced Psychotic Disorder. Instead, Substance Intoxication or Withdrawal, With Perceptual Disturbances, is diagnosed (e.g., Cocaine Intoxication, With Perceptual Dis turbances). "Flashback" hallucinations tha t can occur long after the use of hallucinogens has s top ped are diagnosed as Hallucinogen Persisting Perception Disorder (see p. 253). Moreover, if substance-induced p sychotic symptoms occur exclusively during the cou rse of a delirium, as in some severe form s of AJcohol Withdrawal, the p sychotic sym p toms are considered to be an associated featu re of tlle delirium and are not d iagnosed separatel y. A Substance-Induced Psychotic Disorder is distingu ished from a primary Psychotic Disorder by the fact that a s ubstan ce is judged to be etiologically rela ted to the symptoms (see p. 338). A Substance-Induced Psychotic Disorder due to a prescribed trea tment for a mental or general medical condition must have its onset while the person is receiving the medica tion (or during wi thdrawal, if there is a withdrawal syndrome associated with the medication). Once the trea tment is d iscontinued, the psychotic symptoms will usually remit w ithin days to several weeks (d epending on the hal f-li fe of the s ubstance and the presence of a w ithd rawal syndrome) . If sym p to ms persist beyond 4 weeks, other causes for the psychotic symptoms should be cons idered. Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the p ossibility that the psychotic symptoms are
342
caused by the physiological consequences of the general medical condition rather than the medication, in w ruch case Psych otic Disorder Du e to a General Medical Conditi on is diagnosed . The history often provides the primary basis for s uch a judgment. At times, a change in the treatment for the genera l medical condition (e.g., medication substihltion or discontinuation) may be need ed to determine empirically for tha t person w hether the medication is th e causative agent. If the clinician has ascertained that the d is turbance is due to both a general medical condition and subs tance lise, both diagnoses (i.e., Psych otic Disorder Due to a General Medical Condition and Substance-Induced Psychotic Disorder) may be given. When there is insufficient evidence to determine whether the psychotic symptoms are due to a subs tance (including a medication) or to a general medical condition or are primary (i .e., not due to either a s ubstance or a general medical condition), Psych otic D isorder Not O therwise Sp ecifi ed would be indicated .
Intoxication or Withdrawa l (2) medication use is etiolog ically related to the disturbance
C. The dist urbance is not better accounted for by a Psychotic Disorde r that is not substance induced . Evidence that the symptoms a re better accou nt ed for by a Psychotic Disorder that is not substance in duced might include the follow ing: the symptoms precede the onset of the substance use (or medicat ion use); the symptoms persist for a substantial period of time (e .g., about a month) after the cessat ion of acute withdrawa l or severe intoxication, or are substantially in excess of what would be expected given t he type or amount of the subst ance used or the duration of use; or t here is other evidence that suggests the existence of an independent non-substa nceinduced Psychot ic Disorder (e .g., a history of recurre nt non-substance-re lated episodes) .
D. The disturbance does not occur exclusively d uring t he course of a delirium. Note : This diagnOSis should be made instead of a diagnosis of Substance Intoxicat ion or Substance Withdrawa l only when the symptoms are in excess of those usually associated with the intoxication or withdrawal synd rome and when the symptoms are sufficie ntly severe to warrant independent cli nical attention .
298.9
343 1
298.9
This ca tegory includes psychotic symptomatology (i.e., d elusions, hallucinations, disorga nized s peech, grossly di sorganized or catatonic behavior) abou t which there is inadequate information to make a specific diagnosiS or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific Psychotic Disorder. Examples include
1. Pos tpartum psychosis that d oes not meet criteria for Mood Disorder With Psy chotic Features, Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, or Substance Induced Psychotic Disorder 2. Psychotic symptoms that have lasted for less than 1 month bu t that ha ve not yet remitted, so that the criteria for Brief Psychotic Disorder are not met 3. Persistent auditory hallucinations in the absence o f any other features 4. Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance S. sihJations in which the clinician has concluded that a Psychotic Disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced
Mood Disorders
as the predominant feature. The section is div ided into three parts. The first part describ ~ mood episodes (Major Depressive Episode, Manic Episode, Mixed Episode, and H ypomanic Episode) that have been included separately at the beginning of this section for convenience in diagnosing the various Mood Di sorders. These episodes do not have their own diagnostic codes and cannot be diagnosed as separate entities; however, they s.e rve_as the building blocks for the disorder diagnoses. The second part describes the Mood Disorders (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar I Disorder). The cri teria sets for most of the Mood Disorders require the presence or absence of the mood episodes described in the firs t part of the section, The third part includes the specifiers that describe either the most recent mood episode or the course of recurrent episodes. The Mood Disorders are divided into the Depressive Disorders ("unipolar depression"), the Bipolar Disorders, and two disorders based on etiology-Mood Disorder Due to a General Medical Condition and Substance-Induced Mood Disorder. The Depressive Disorders (i .e., Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified) are di stinguished from the Bipolar Disorders by the fact that there is no history of ever having had a Manic, Mixed, or Hypomanic Episode. The Bipolar Disorders (i.e., Bipolar I Disorder, Bipolar n Disorder, Cyclothymic Disorder, and Bipolar Disorder Not Otherwise Specified) involve the presence (or history) of Manic Episodes, Mixed Episodes, or H ypomanic Episodes, usually accompanied by the presence (or history) of Major Depressive Episodes. Major Depressive Disorder is characterized by one or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four addi tional symptoms of depression). Dysthymic Disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode. Depressive Disorder Not Otherwise Specified is included for coding disorders with depressive features that do not meet criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjusbnent Disorder With Mixed Anxiety and Depressed Mood (or depressive symptoms about which there is inadequate or contradictory information). Bipolar I Disorder is characterized by one or mOTe Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes. Bipolar II Disorder is characterized by one or m ore Major Depressive Episodes accompanied by at least one H ypomanic Episode.
345
346
Mood Disorde rs
Cyclothymic Disorder is characterized by at least 2 years of numerous p eriods of hypoma nic symptoms that do not meet criteria for a ~<lanic Episode a nd numerous pe riods of depressive symptoms that do not meet crite ria fo r a Major Depressive Episode. Bipolar Disorder Not Othe nvise Specified is included for coding disorders with bipolar featu res that do not meet criteria for any of the specific Bipolar Disorders defined in this section (or b ipolar symptoms about which there is inadequate Of contra dictory information). Mood Disorder Due to a Genera l Medical Cond ition is characterized by a prominent and persistent d isturbance in mood that is judged to be a direct physiological consequence of a general medica l condition. Subs tance-Induced Mood Disorder is characterized by a prominent and persistent d ishlTbance in mood that is judged to be a direct physiological consequence of a drug of abuse, a m ed ication, another somatic treatment fo r depression, or toxin exposure. Mood Disorder Not Othenvise Specified is included for coding disorders with mood symptoms that do not meet the criteria for an)' specific Mood Disorder and in which it is difficult to choose between Depressive Disorder .o t Otherwise Specified and Bipolar Disorder Not Otherwise Specified (e.g., acute agi tation). The s pecifiers described in the third part of the section are provided to increase diagnostic specificity, create more homogeneous s ubgroups, assist in trea tment selection, and improve the prediction of prognosis. Some of the specifiers describe the clinical status of the current (or most recent) mood episode (i.e., SeveritylPsychotiC/ Remission Specifiers), w hereas others describe fea tu res of the current episode (or mos t recent episode if the ep isode is currently in partial or fu ll remission) (i.e., C hronic, With Catatonic Features, With Melancholic Features, With Atypical Features, With Postpartum Onset). Table 1 (p . 411 ) indicates which episode specifiers apply to each codable Mood Disorder. Other sp ecifiers describe the course of recurrent mood episodes (i.e., longitudinal Course Specifiers, With Seasonal Pattern, With Rapid Cycli ng). Table 2 (p. 424) ind icates which course specifiers apply to each codable Mood Disorder. The specifiers that indicate severity, rem ission, and psychotic fea h l.res can be coded in the fifth d ig it of the diagnostic code fo r most of the Mood Diso rders. The other specifiers ca nnot be coded. The Mood Disorders section is organized as follow s: Mood Episodes Major Depressive Episode (p . 349) tI.<fanic Episode (p . 357) Mixed Episode (p . 362) Hypomanic Episode (p . 365) Depressive Disorders 296.xx Major Depressive Disorder (p . 369) 300.4 Dysthymic Diso rder (p. 376) 311 Depressive Disorder Not O thenvise Sp ecified (p . 381)
Mood Diso rders Bipolar Diso rders 296.xx Bipolar I Disord er (p. 382) 296.89 Bipolar II Disorder (p. 392) 301.1 3 Cyclothymic Disord er (p. 398) 296.80 Bip olar Disorder No t Otherwise Specified (p. 400) Other Mood Disorders 293.83 Mood Disorder Due to . .. [Judica te tile Geflcrnl Medical COlldil ioll/ (p. 401 ) 29x.xx Su bs ta nce~lnduced Mood Disorder (p. 405) 296.90 Mood Disorder Not Othemise Sp ecified (p. 410) Specifiers d escribing the clini cal status of the current (or m ost recent) mood episod e J\oWd, Moderate, Severe Witho ut Psychotic Features, Severe With Psychotic feah u es, In Partial Remission, In Full Remission (for Major Depressive Episode, p. 41 1; fo r Manic Episode, p. 413; for Mixed Episode, p. 415) Specifiers d escribing features of the curre nt episode (or most recent episo de if cu rrently in partial or full remission)
Clu-onic (p . 41 7)
With Catatonic Features (p. 4 17) With Melancholic Features (p. 419) With Atypical f eatures (p. 420) With Postpa rtum Onset (p. 422) Specifiers describing course of recurrent episodes Longitudinal Course Specifiers (With and Without Full lnterepisode Recovery)
(p . 424)
Reco rding Procedures for Majo r Depressi ve Disord er and Bipolar I and Bipolar II Disorders
Selecting diagnostic codes. The diagnostic codes are selected as foll ows: For Major Depressive Disorder:
1. The first three digits are 296. 2. The fourth digit is ei ther 2 (if there is only a single Major Depressive Epi~
sode) or 3 (if there are recurrent Major Depressive Ep isod es). 3. The fifth digit indicates the severity of the current Major Depressive Epi~ sode if full criteria are met as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Wi thout Psycho tic Features, 4 for Severe With Psy~ chotic Features. If full criteria are not currently met fo r a Major Depressive Episode, the fifth d igit indicates the current clinical status of the Major Depressive Disorder as follows: 5 for In Partial Remission, 6 for In Full Re~ mission. Ii current severity or clinical status is unspecified , the fifth digit is O.
348
For Bipolar I Disorde r:
1. The fi rst three digits are also 296.
Mood Disorders
2. The fourth d igit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth d igi t indicates the nature of the current episode (or, if the Bipolar I Disorder is currently in partial or full remission, the nahue of the most recen t episode) as follows: 4 if the current or most recent episode is a Hypomanic Episode or a Manic Episode, 6 if it is a Mixed Episode,S if it is a Major Depressive Episode, and 7 if the current or most recent episode is Unspecified . 3. The fifth d igit (except (or Bipolar I Disorder, Most Recen t Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the severity of the current episode if full criteria are met for a Manic, Mixed, or Major Depressive Episode as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features, 4 for Severe With Psychotic Features. If full criteria are not met for a Manic, lvlixed, or Major Depressive Episode, the fifth digit indicates the current clinica1 status of the Bipolar I Disorder as fo llows: 5 for In Partial Remission, 6 for In Ful l Remission. If current severity or clinical status is WlSpecified, the fifth digit is O. For Bipola r I Disorder, Most Recent Episode Hypomanic, the fifth digit is always O. For Bipolar Disorder, Most Recen t Episode Unspecified, there is no fifth digi t.
For Bipolar II Disorder, the diagnostic code is 296.89. Recording the name of the diagnosis. in recording the name of a diagnosis, terms should be listed in the following order:
1. Name of disorder (e.g., Major Depressive Disorder, Bipolar Disorder)
2. Specifi ers coded in the fourth digi t (e.g., Recurrent, Most Recent Episode Manic) 3. Specifiers coded in the fifth digit (e.g., Mild, Severe With Psychotic Fea tures, In PartiaJ Rem ission) 4. As many specifiers (without codes) as apply to the current or most recent episode (e.g., With Melancholic Features, With Postpartum Onset) 5. As many specifiers (without codes) as apply to the course of recurrent episodes (e.g., With Seasonal Pattern, With Rapid Cycling) The following examples illustrate how to record a Mood Disorder diagnosis with specifiers: 296.32 Major Depressive Disorder, Recurrent, Moderate, With Atypical Featu res, With Seasonal Pattern, With Fulllnterepisod e Recovery 296.54 Bipola r I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, With Melancholic Features, With Rapid Cycling
Mood Episodes
Mood Episodes
Mood Disorders
may be a significant loss or gain in weight, or, in children, a fa ilure to make exp ected weight gains may be noted (Criterion A 3). The most common s leep d is turbance associated w ith a Major De pressive Episode is insomnia (Crite rion A4). Ind ividuals typically have midd le insomnia (i.e., w aking up during the nig ht a nd having difficulty returning to sleep) o r terminal insomnia (i.e., waking too early and being u nable to return to s leep). Wtial insomnia (i.e., difficu lty fa lling aslee p) may also occur. Less frequently, individuals present with overs leep ing (hypersomnia) in the form of prolonged sleep episodes at nigh t or increased d aytime sleep. Sometimes the reason that the individual seeks treahnentis for the d isturbed sleep. Psychomotor changes include agita tion (e.g., the inability to sit s till, pacing, han dw ringin g; or pu lling or rubbing of the skin, clothing, or o ther objects) or retard ation (e.g., s lowed speech, thinking, and body movemen ts; increased pa uses before answering; sp eech tha t is decreased in volume, inflection, a mount, o r variety of conten t, or mu teness) (Criterion AS). The psychomotor agi tation or re tarda tion mus t be severe e nough to be observable by others and not re present me rely s ubjective feelin gs. Decreased energy, tiredness, and fa tigue are com mon (Crite rion A6). A person may report sustained fa tigue w ithou t ph ysical exertion. Even the smallest tasks seem to require substantial effort. The effidency w ith w hich tasks a re accomplished may be reduced . For examp le, an individ ual may com plain that washing and dreSSing in the morning are exhaus ting a nd take h " ice as long as usual. The sense of worthlessness or guilt associated with a Major Depressive Episode may include unrealis tic nega ti ve evaluations of one's worth or guil ty p reoccupa tions or rumina tions over m inor pas t failin gs (Criterion A7). Such individ uals often misinte rpret ne u tral or trivial d ay-to-d ay events as e vidence o f personal defects and have a n exaggera ted sense of responsibility for untoward events. Fo r example, a realtor m ay become preoccupied with self-bla me for fai lin g to make sales even w he n the ma rket has collapsed generally a nd o ther realtors a re equally una ble to m ake sales. The sense of worthlessness or guilt may beof d elusional p roportions (e.g., a n individual who is convinced tha t he or sh e is personally responsible for world p overty). Blaming oneself for being sick a nd for failing to meet occu pational or interpersonal respons ibilities as a resu lt of the dep ression is very common a nd, unless delus ional, is not considered sufficie nt to meet this criterion . Many individuals re port impaired ability to th in k, concen trate, or make decisions (Crite rion AS). They may appear eas ily dis tracted or com p lain of memory difficulties. Those in intellectually de manding acade mic or occupational pu rsuits are oflen unable to function adequately even when they have mild concen tra tion p rob lems (e.g., a compu te r p rogrammer who can n o longer perform com p licated but previously manageable tasks). In child ren, a precipitous drop in grades may re nect poor concentration. In elderly ind ividuals with a Major Depressive Episode, me mory difficulties may be the chief complaint an d may be mis taken for ea rly signs of a d ementia ("pseudodementia"). When the Major Depressive Episode is s uccessfully treated, the memory p roble ms often full y aba te. However, in some indiv idlla ls, pa rticularly elderly persons, a Major Dep ressive Episod e may sometimes be the in itial presen tation of an irreversible d ementia. Frequently there may be thoug hts of death, suicidal ideation, or suicid e attempts (Criterion A9). These thoughts ran ge from a belief tha t others wou ld be bette r off if
351
the person were dead, to transient but recurrent thoughts of committing suicide, to actual s pecific plans of how to conun i! suicide. The frequency, intensity, and lethality of these thoughts can be quite variable. Less severely suicidal individuals may report transien t (l~ to 2-minute), recurren t (once or twice a week) thoughts. More severely suicidal individuals may have acquired materials (e.g., a rope o r a gun) to be used in the suicide attempt and may have established a location and time when they will be isolated from o thers so that they can accomplish the suicide. Although these behav~ iors are associa ted statistically with suicide attempts and may be helpful in identi fy~ ing a high~ris k group, many studies have shown that it is not possible to predict accurately whether or when a particular individual with depression w ill attempt sui ~ cide. Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles or an in tense wish to end an excruciatingly painful emotional state that is perceived by the person to be without end. A diagnosis o f a Major Depressive Episode is not made if the symptoms meet criteria for a Mixed Ep isode (C riterion 6). A Mixed Episode is characterized by the symptoms of both a ~'[anic Episode and a Major Depressive Episode occurring nearly every day for at least a I -week period. The deg ree of impairmen t associated with a Major Depressive Episode varies, bu t even in mild cases, there must be either clinically significant distress or some interference in social, occupational, or other important areas of fun ctioning (Criterion C). If impairment is severe, the person may lose the ability to hmction socially or occupationally. In extreme cases, the person may be unable to perform minimal self-care (e.g., feeding or clothing self) or to maintain m inimal personal hygiene. A careful interview is essential to elicit symptoms of a Major Depressive Episode. Reporting may be compromised by difficulties in concentrating, impaired memory, or a tendency to den y, di scount, or explain away symptoms. Information from additional informants can be especially helpful in clarify ing the course of current or prior Major Depressive Episodes and in assessing whether there have been any Manic or Hypomank Episodes. Because Major Depressive Episod es can beg in gradually, a review of clinical infomlation that focuses on the worst part of the current episode may be most likely to detect the presence of symptoms. TIle evaluation of the symptoms of a Major Depressive Episode is especially difficult when they occur in an indiv idual who also has a general medical condi tion (e.g., cancer, stroke, m yocardial infarction, diabetes) . Some of the cri terion items of a Major Dep ressive Ep isode are identical to the characteristic signs and symptoms of general medkal conditions (e.g., weight loss with untrea ted diabetes, fatigue with cancer). Such symptoms shou ld count toward a Major Depressive Episode except when they are d early and fu lly accoun ted for by a general medical condition. For example, weight loss in a person with ulcerative colitis who has many bowel movements and little foo d intake should not be counted toward a Major Depressive Episode. On the other hand, when sadness, guilt, insonmia, or weight loss a re p resent in a person with a recent myocardial infarction, each symptom would count toward a Major Depressive Episode because these are not clearly and fully accounted for by the physiological effects of a myocardial infarction. Similarly, when symptoms are clearly due to mood-incongruent delusions or hallucinations (e.g., a 30-pound weight loss rela ted to not eating because of a delusion tha t one's food is being poisoned), these symptoms do not count toward a Major Depressive Episode.
Mood Disorders By definition, a Major Depressive Episode is not due to the direct physiological effec ts of a drug of abuse (e.g., in the contex t of Alcohol In toxication or Cocaine Withd rawal), to the side effects o f medications or treatments (e.g., steroids), or to toxin exposure. Similarly, the episode is not due to the direct physiological effects of a general medical condition (e.g., hypothyroidism) (Cri terion D). Moreover, if the symptoms begin within 2 months of the loss of a loved one and do not persist beyond these 2 months, they are generally considered to result from Bereavement (see p. 740), un1ess they are associa ted with marked functional impairment or include morbid preoccupation w ith worthlessness, su icida l ideation, psychotic symptoms, or psychomotor retardation (C riterion E).
353
longed sleep latency, increased intermittent wakefulness, and early morning awakening; 2) reduced non-rapid eye movement (NREM) stages 3 and 4 sleep (slow-wave sleep), with a shift in slow-wave activity away from the first NREM period; 3) decreased rapid eye movement (REM) latency (i.e., shortened duration of the first N REM period); 4) increased phasic REM activity (i.e., the number of actual eye movemen ts during REM); and 5) increased duration o f REM sleep early in the night. There is evidence that these sleep abnormalities may persist after clinical remission o r precede the onset of the initial Major Depressive Episode among those at high risk for a Mood Disorder (e.g., first-degree family members of individuals wi th Major Depressive Disorder). The pathophysiology of a Major Depressive Episode may involve a dysregulation of a number of neurotransmitter systems, including the serotonin, norepinephrine, dopamine, acetylcholine, and gamma-aminobu tyric acid s}'stems. There is also evidence of alterations of several neuropeptides, including corticotropin-releasing hormone. In some depressed individuals, hormonal disturbances have been observed, including elevated g lucocorticoid secretion (e.g., elevated urinary free cortisol levels or dexamethasone nonsuppression of plasma cortisol) and blunted grow th hormone, thyroid-stimulating hormone, and prolactin responses to various chaUenge tests. Functional b rain imaging studies document altera tions in cerebral blood flow and metabolism in some individuals, indud ing increased blood flow in lim bic and paralimbi c regions and decreased blood fl ow in the lateral prefron tal cortex. Depression beginning in late life is associa ted with alterations in brain structure, including periventricular vascular changes. one of these changes are present in all individua ls in a Major Depressive Episode, however, nor is any particular dis turbance specific to depression.
354
Mood Disorders
symptoms may change w ith age. Certain symptoms such as somatic complaints, irritabili ty, a nd social withdrawal are particularly com mon in children, whereas p sychomotor retardation, hypersomn ia, and delusions are less conunon in prepuberty than
in adolescence and adulthood. In prepubertal children, Major Depressive Episodes occur more frequentl y in conjunction with other mental disorders (especially Disruptive Behav ior Disorde rs, A ttention-Deficit Disord ers, and Anxiety D is orders) than in isolation. In adolescents, Major Depressive Episodes are frequently associated w ith Disruptive Be havior Dis orders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Rela ted Disorders, and Eating Disorders. In elderly adults, cognitive symptoms (e.g., disorientation, memory loss, and distractibility) may be particularly p rominen t. Women are at significantly greater risk than m en to develop Major Depressive Episodes at some point during their lives, with the greatest differences found in studies conducted in the United States and Europe. This increased differential risk emerges during adolescence and may coincide with the onset of puberty. Thereafter, a significant proportion of women report a worsening of the sy mptoms of a Major Depressive Episode several days before the onset of menses. Studies indicate that depressive episodes occur h" ice as frequently in women as in men. See the corresponding sections of the texts for Major Depressive Disorder (p. 372), Bipolar I Disorder (p. 385), and Bipolar n Disorder (p. 394) fo r specific information on gender.
Cou rse
Symptoms of a Major Depressive Episode usually develop over d ays to weeks. A prodromal period that may include anxiety symptoms and mUd d epressive symptoms may last for weeks to months before the onset of a full Major Depressive Episode. The duration of a Major Depressive Episode is also variable. An untreated episode typicaUy lasts 4 months or longer, regard less o f age at onset. In a majori ty of cases, there is complete remission of symptoms, and functioning returns to the premorbid level. In a significant proportion of cases (perhaps 20%-30%), some depressive symptoms insufficient to meet full criteria fo r a Major Depressive Episode may persist for months to years and may be associated with some disabili ty or distress (in which case the specifier In Partial Remission may be noted; p. 412). Partial remission followin g a Majo r Depressive Episode appears to be predictive of a similar pattern afte r subsequent episodes. In some individuals (S'Yn-10%), the fu l1 criteria for a Major Depressive Episode continue to be met for 2 or more years (in which case the specifier Chronic may be no ted; see p. 417).
Differential Diagnosis
A Major Depressive Episode must be distinguished from a Mood Disorder Due to a General Medical Condition. The appropriate diagnosis would be Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct p hysiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyrOi dism) (see p. 401). This d etermination is based on the history, laboratory findings, or physical examination. Uboth a Major Depressive Episode and a general medical condition are present but it is judged that the depressive symptoms
Major Depressive Episode are not the direct p hysiologica l consequence o f the general medical condition, then the primary Mood Disorder is recorded on Axis I (e.g., Major Depressive Disorder) and the general medical condition is record ed on Axis III (e.g., myocardial infarction). This would be the case, for examp le, if the Major Depressive Episode is consid ered to be the psychological consequence of having the general medical condition o r if there is no etiological relationship between the Major Depressive Episode and the general medical condition. A Substance Induced Mood Disorder is distinguished hom a Major Depressive Episode by the fa ct that a substance (e.g ., a drug of abuse, a medication, or a toxin) is judged to be etiologically related to the mood dishubance (see p. 405). For example, depressed mood tha t occurs on ly in the con text of withdrawal from cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal. In elderly p ersons, it is often difficult to determine whether cognitive symptoms (e.g., disorientation, ap athy, difficulty concentrating, memory loss) are better accounted for by a dementia or by a Major Depressive Episode. A thorough medical evaluation and an evaluation of the onset of the disturbance, tempora l sequencing of depressive and cognitive symptoms, course of illness, and treatment resp onse are helpful in making this determination. The p remorbid state of the individual may help to differentiate a Major Depressive Episode from a dementia. In a dementia, there is usually a premorbid history o f d eclining cogn itive function, whereas the individual with a Major Dep ressive Episode is much more likely to have a relatively normal premorbid state and abrupt cognitive decline associated with the depression . Major Depressive Epi sodes w ith promin ent irritable mood may be difficult to distinguish from Manic Episod es with irritab le mood or from Mixed Episodes. Thi s distinction requires a careful clinical evalua tion of the p resence of manic symptoms. If criteria arc met for both a Manic Episode and a Major Depressive Episode (except fo r the 2-weck duration) nearly every day for at least a l-week period, this would constitute a Mixed Episode. Distractibility and low fru stration tolerance can occur in both Attention-Deficitl Hyperactivity Di sorder and a Major Depressive Episode; if the criteria are met for both, Attention-Deficit/ Hyperactivity Disorder may be diagnosed in addition to the Mood Disorder. However, the clinician must be cau tious not to overdiagnose a Major Depressive Episode in children w ith Attention-Deficit/ Hyperactivity Disorder whose disturbance in mood is characterized by irritability rather U,an by sadness or loss of interest. A Major Depressive Episode tha t occurs in resp onse to a p sychosocia l stressor is distinguished from Adjustment Disorder With Depressed Mood by the fact that the fu Ucriteria for a Major Depressive Episode are not met in Adju shnen t Disorder. After the loss of a loved one, even if depressive symptoms are of sufficient duration and number to meet criteria for a Majo r Depressive Episode, they should be attribu ted to Bereavement ra ther than to a Major Depressive Episode, unless they persist fo r more than 2 months or include marked functi onal impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psydlOmotor retardation. Finally, p eriod s of sadness are inherent aspects of the human experience. These periods should not be diagnosed as a Major Depressive Episode wlless criteria are met for severity (Le., five out of nine sympto ms), duration (i.e., most of the day, nearly
356
Mood Disorders
every day for at least 2 weeks), and clinically significant distress or impairment. The diagnosis Depressive Disorder Not Othenvise Specified may be appropriate for p resentations of depressed mood with clinically significant impairmen t that do not meet criteria for duration or severity.
period and represent a change from previous function ing; at least one of the symptoms is either (ll depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note : In chi ldren and adolescents, can be irritable mood. markedly diminished interest or pleasure most of (~ the day, nearly every day (as indicated by in all, or almost all, activitiesobservaeither subjective account or tion made by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure t o make expected weight gains. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day ':'(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (nat merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indeciSiveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 8. The symptoms do not meet criteria for a Mixed Episode (see p. 365).
C. The symptoms cause clinically significant distress or impairm ent in social, occupational. or ather important areas of functioning.
D. The symptoms are nat due to the direct phYSiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroid ism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic ~mptoms, or psychomotor retardation.
Manic Ep isode
357
Manic Episode
Ep isode Features
A r.,< fanic Episode is defined by a distinct period during which there is an abnormally and persistently eleva ted, expansive, or irri table mood. This period of abnormal mood must last at least 1 week (or less if hospitalization is required) (Criterion A). The mood disturbance must be accompanied by at least three additional symptoms fro m a list that includes infla ted self-esteem or grandiosity, decreased need for sleep, pressure of speech, rught o f ideas, distractibility, increased involvement in goaldirected activities or psychomotor agitation, and excessive involvement in pleasurable activities with a h igh potential for painful consequences. If the mood is irritable (rather than elevated or expansive), at least four of the above symptoms must be present (Criterion B). The symptoms do not meet criteria for a Mixed Episode, which is characterized by the s}'mptoms of both a Manic Episode and a Major Depressive Episode occurring nearly every day for a t least a I-week period (Criterion C). The dis turbance must be sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization, or it is characterized by the presence of psychotic features (Criterion D). The episode must not be due to the direct physiological effects of a drug of abuse, a medication, other somatic treatments for depression (e.g ., electroconvu lsive therapy or light therapy), or toxin exposure. The episode must also not be due to the direct physiological effects of a general medical condition (e.g., multiple sclerosis, brain tumor) (C riterion E). The elevated mood of a Manic Episode may be described as euphoric, unusually good, cheerful, or high. Although the person's mood may initia lJy have an infectious quality for the uninvolved observer, it is recognized as excessive by those who know the person well. The expansive quality of the mood is characterized by unceasing and indiscriminate enthusiasm for interpersonal. sexual, or occupational interactions. For example, the person may spontaneously start extensive conversations with strangers in publiC places, or a salesperson may telephone strangers at home in the early morning hours to initiate saJes. Although elevated m ood is considered the prototypical symptom, the predominant mood disturbance may be irritability, particulilfly when the person's wishes are thwarted. Labili ty of mood (e.g., the aJtemation between euphoria and irritabili ty) is frequently seen. In nated self-esteem is typically present, ranging from uncritica l self-confidence to marked grandiosity, and may reach d elusional proportions (Criterion Bl). Individuals may give advice on matters about wh ich they ha\'e no special knowledge (e.g., how to run the United Nations). Despite lack of any particular experience or talent, the individual may embark on writing a novel or composing a symphony or seek publicity for some impractical invention. Grandiose delusions are common (e.g., having a special relationship to God or to some public figure from the political, religiOUS, or entertainment world). Almost invar iably, there is a decreased need for sleep (Criterion B2). The person usually awakens several hours earlier than usual, feeli ng fu ll of energy. When the sleep disturbance is severe, the person may go for d ays without sleep and yet not feel tired.
Mood Disorders Manic speech is typically pressured, loud, rapid, and difficult to interrupt (C riterion 83). Ind ividuals m ay talk nonstop, sometimes for hours on end, and without regard for others' wishes to commun icate. Speech is sometimes characterized by joking, punning, and amusing irrele\'ancies. The individual may become theatrical, with dramatic mannerisms and singing . Sounds rather than meaning ful conceptual relationships may govern word choice (i.e., clanging). If the person's m ood is more irritable than expansive, speech may be marked by complaints, hostile comments, o r angry tirad es. The individual's thoughts may race, often at a rate faster than can be articulated (Criterion 84). Some individuals with Manic Episodes report that this experience resembles watching two or three television programs simultaneously. Frequently there is flight of ideas evidenced by a nearly continuous flow of accelerated speech, with abrupt changes from one topic to another. For example, while talking about a potential business deal to sell computers, a salesp erson may shift to discussing in minute detail the history of the computer chip, the industrial revolu tion, or applied mathematics. When flight of id eas is severe, sp eech may become disorgani zed and incoherent. Distractibili ty (Criterion 85) is evidenced by an inability to screen ou t irrelevant external stimuli (e.g., the interviewer's tie, backg round noises or conversations, or furni shings in the room). There ma y be a reduced ability to d ifferentiate beh ,'een thoughts that are germane to the topic and thoughts tha t are only slightly relevant or clearly irrelevant. TIle increase in goal-d irected activity often involves excessive plarming of, and excessive participation in, muJtiple activities (e.g., sexual, occupational, political, religiOllS) (Criterion B6). Increased sexual drive, fanta sies, and behavior are often presen t. The p erson may simultaneously take on multiple new business ventures without regard for the apparent risks or the need to complete each ven ture satisfactorily. Almost in variably, there is increased sociability (e.g., renewing old acquaintances or calling fri ends or even strangers at aU hours of the d ay o r night), without regard to the intrusive, d omineering, and demanding na ture of these interactions. Indi viduals often disp lay p sychomotor ag itation or restlessness by pacing or by holding muJtip le conversations simuJtaneously (e.g., by telephone and in person at the same time). Some indi viduals write a torrent of letters on many different topics to friends, public fi gures, or the med ia. Expansiveness, unwarran ted optimism , g randiosity, and poor judgment often lead to an imprudent involvemen t in pleasurable activities such as buying s prees, reckless driving, fooHsh business investments, and sexual behavior unusual for the person, even though these activities are likely to have painful consequences (Criterion 87). The individual may purchase many uJU"lccded items (e.g ., 20 pairs of shoes, expensive antiques) without the money to pay for them. Unusual sexual behavior may include infidelity o r ind iscriminate sexual encounters with strangers. TIle im pairment resulting from the dishtrbance must be severe enough to cause marked impairnlent in fun ctioning or to require h ospitalization to protect the individual from the negative consequences of actions that resuJt from poo r judgment (e.g., financial losses, illegal activities, loss of employment, assaultive behavior). By definition, the presence of psychotic features during a Manic Episode constitutes marked impaim,ent in fun ctioning (Criterion D). Symptoms like those seen in a Manic Episode may be due to the direct effects of
Manic Episode
359
antidepressant medication, electroconvulsive therapy, light therapy, or medication prescribed for other general medical conditions (e.g., corticosteroids). Such presen tations are not considered Manic Episodes and do not count toward the diagnosis of Bipolar I Disorder. For example, if a pcrson with recurrent Major Depressive Disorder develops manic symptoms following a course of antidepressant medication, the episode is diagnosed as a Substance-Induced Mood Disorder, With Manic Features, and there is no switch from a diagnosis of Major Depressive Disorder to Bipolar I Disorder. Some evidence suggests that there may be a bipolar "diathesis" in individuals who d evelop manic-like episodes foU owing somatic treatment for depression. Such individuals may havc an increased likelihood of future Manic, Mixed, or Hypomanic Episodes thai are not related to substances or somatic treatments for depression . This may be an especially important consideration in children and adolescents.
1 360
Mood Disorders
abnormalities and increased. cortisol secretion. There m ay be abnormalities involving the norepinephrine, serotonin, acetylcholine, dopamine, or gammaaminobutyric ad d neurotransmitter systems, as demonstrated by studies of neurotransmitter metabo-
Course
The mean age at on set for a fi rst Manic Ep isode is the early 20s, but some cases start in adolescence and o thers start after age 50 years. Manic Ep isodes typically begin s uddenly, with a rapid escalation o f symp toms over a few d ays. Frequently, Man ic Episodes occur following psychosocia l stressors. The episodes us ually last from a few weeks to several mon ths and a re briefer and end more abruptly than Major Depressive Episodes. In many instances (500/0-60%), a Major Dep ressive Episod e immediately p recedes or immedi ately follows a Manic Episode, w ith n o intervenin g period of eu thymia. If the Manic Episod e occurs in the postpartum period, there m ay be an increased risk for recurrence in subsequent postpartum p eriods and the s pecifier With Postpartum Onset is applicable (see p. 422).
Differential Diagnosis
A Manic Episode must be distinguished from a M ood Di sorder Due to a Ge neral M edical Condition . The appropria te diagnosis would be Mood Disorder Due to a General Med ical Cond ition if the m ood d isturbance is judged to be the direct physiological consequence o f a specific genera l medical condition (e.g., multiple sclerosis, brain tumor, C ushing's syndrome) (see p. 401). This d etem \ina tion is based on the history. laboratory fi ndings, or physica l examination . If it is judged that the manic s}'m p toms are not the d irect physiological consequence of the genera l medica l condition, then the primary Mood Disorder is recorded on Axis I (e.g ., Bi polar I Di sorder) and the general medical cond ition is recorded on Axis III (e.g., myoca rdial infarction). A late onset o f a fi rsl Manic Episode (e.g., after age 50 years) should alert the clinician to the possibility of an etiological general medical cond ition or substance. A Sub stancelndu ced M ood Disorder is distinguished from a Manic Episode by the facl that a substance (e.g., a d rug of abuse, a med ica tion, or exp osure to a toxin) is judged to be etiologica lly related to the mood distu rbance (see p . 405). Sym p toms like
Ma nic Episode
361
those seen in a Manic Episode may be precipitated by a drug of abuse (e.g., manic symptoms that occur only in the context of intoxication w ith cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Manic Features, With Onset During lntoxica tion). Symptoms like those seen in a Manic Episode may also be precipitated by an tidepressant treatmen t such as medication, electroconvulsive therapy, or light therapy. Such episodes are also d iagnosed as Substance-Induced Mood Disorders (e.g., Amitriptyline-Induced Mood Disorder, With Manic Fea tures; Electroconvulsive Therapy-Induced r.,'lood Disorder, Wi th Manic Features). However, clinica l judgment is essential to d etermine whether the treatment is truly causal or whether a p rimary Manic Episode happened to have its onset while the person was receiving the treMment (see p. 406). Manic Episodes should be distinguished from Hypomanic Episodes. Although Manic Episod es and Hypomanic Episodes have an identical list of characteristic symp toms, the distu rbance in Hypo manic Episod es is not sufficiently severe to cause marked im pairmen t in socia l or occupationaJ fllflCtiOning o r to require hospitalization. Some Hypomanic Episodes may evolve into fu ll Manic Episod es. Major D ep ressive Episodes w ith prom inent irritable mood may be difficult to distinguish from Manic Episodes w ith irritable mood or from Mixed Episodes. This determination requires a careful clinical evaluation of the presence of manic symptoms. U criteria are met for bo th a Manic Episode and a Major Dep ressive Episode nearl}' every d ay for at least a l-week period, th is would constitute a Mixed Episode. Attention-DeficitIHyperactivity Disorder and a Manic Episod e are both characterized by excessive acti vity, impulsive behavio r, poor jud gmen t, and denial of p roblems. Attention-Deficit/ Hyperactivity Disorder is d isting uished from a Manic Episod e by its characteristic early onset (i.e., before age 7 )'ears), chronic rather than episodic cou rse, lack o f relatively clear onsets and o ffsets, and the absence o f abnorma U expansive or eleva ted mood or psychotic fe atures. y
1 362
Mood Disorders
cant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g .. feels rested aft er only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant externa l stimuli) (6) increase in goal-d irected activity (either socially, at work or school, or sexually) or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e .g., engaging in unrestrained buying sprees, sexua l indiscretions, or foolish business invest ments)
C. The symptoms do not meet criteria fo r a Mixed Episode (see p. 365).
D. The mood disturbance is sufficiently severe to cause marked impairment in occupat ional functioning or in usua l social activit ies or relationships with others, or to necessitate hospita lization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other t reatment) or a general medical condition (e.g., hyperthyroidism). Note: Manic-like episodes that are clea rly caused by somatic ant idepressant treatment (e.g., med ication, electroconvulsive therapy, light therapy) should not count toward a diag nosis of Bipolar I Disorder.
Mixed Episode
Episode Featu res
A Mixed Episode is characterized by a period of time (lasting at least 1 week) in which the criteria are met both for a Man ic Episode and for a Major Depressive Episode nearly every day (Criterion A). The individual experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of a Manic Episode (see p. 357) and a Major Depressive Episode (see p. 349). The symptom presentation fre quently includes agitation, insomnia, appetite d ysreguJation, psychotic features, and suicidal thinking. The disturbance must be sufficiently severe to cause marked impairment in social or occupational fun ctioning or to require hospitalization, Dr it is
Mixed Episode
363
characterized by the presence of psychotic features (Criterion B). The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism) (Criterion C). Symptoms like those seen in a Mixed Episode Illay be due to the di rect effects of antidepressant medication, electroconvulsive therapy, light therapy, or medication prescribed for other general med ical conditions (e.g., corticosteroids). Such presentations are not consid ered Mixed Episodes and do not count toward a d iagnosis of Bipolar I Disorder. For example, if a person with recurrent Major Depressive Disorder develops a mixed symptom picture during a course of antidepressant medication, the diagnosis of the episode is Substance-Induced Mood Disorder, With Mixed Features, and there is no switch from a diagnosis of Major Depressive Disorder to Bipolar I Disorder. Some evidence suggests that there may be a bipOlar "diathesis" in individuals who develop mixed-like episodes following somatic treatment for depression. Such individuals may have an increased likelihood of future Manic, Mixed, or Hypomanic Episodes that are not related to substances o r somatic treatments for depression. This may be an especially important considera tion in children and adolescents.
Cou rse
Mixed Episodes can evolve from a Manic Episode or from a Major Depressive Episode or may arise de novo. For example, the diagnosis would be changed from Bipolar I Diso rder, Most Recent Episode Manic, to Bipola r I Disorder, Most Recent Episode Mixed, for an individual with 3 weeks of manic symptoms followed by 1 week of both manic symptoms and depressive symptoms. Mixed episodes may last weeks to several months and may remit to a period with few or no symptoms or evolve into a Major Depressive Episode. It is far less common for a Mixed Episode to evolve into a Manic Episode.
Mood Disorders
Differential Diagnosis
A Mixed Episode mus t be d istinguished from a Mood Disorder Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Med ical Condition if the mood disturbance is judged to be the direct physiological consequence of a sp ecific general medical condition (e.g ., multi ple sclerosis, b rain tlUllOf, Cushing's syndrome) (see p . 401). This determination is based on the his tory, laboratory findings, or physical examination. If it is judged that the mixed manic and depressive sym ptoms are not the direct physiological consequence of the general medical condition, then the prim ary Mood Disorder is recorded on Axis I (e.g ., Bip olar I Disorder) and the general medical condition is recorded on Axis 11l (e.g., myocardial infarction). A Substance-Induced Mood Disorder is distinguis hed from a Mixed Episode by the fact tha t a substance (e.g., a drug of abuse, a medication, or exp osure to a toxin) is judged to be etiologically related to the mood disturbance (see p. 405). Symptoms like those seen in a Mixed Episode may be precipitated by use of a drug o f abuse (e.g., mixed manic and depressive symptoms that occur only in the con tex t of intoxica tion with cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Mixed Features, With Onset During Intoxication). Symptoms like those seen in a Mixed Episode may also be precipitated by antidepressant treatment such as medication, electroconvulsive therapy, or light therapy. Such episodes are also diagnosed as Substance-Ind uced Mood Disorders (e.g ., Amitriptyline-Induced Mood Disorder, With Mixed Features; Electroconvulsive Therapy~Induced Mood Disorder, With t>.1ixed Feahlres). However, clinical judgment is essential to determine whether the treatment is truly causal or whether a primary Mixed Episode happ ened to have its onsct while the person was receiving the treatment (see p. 406). Major Depressive Episodes w ith prominent irritable mo od and Manic Episodes with prominent irritable mood may be difficult to distinguish from Mixed Episodes. This d etermination requi res a carefu l clinical evaluation of the simultaneous presence of symptoms that are characteris tic of both a full Manic Episode and a full Major Depressive Episode (except for duration). Attention-Deficit/Hyperactivity Disorder and a Mixed Episode are both ch aracterized by excessive activity, impulsive behavior, p oor ju dgment, and denial of problems. Attention-Deficit/ Hyp eractivity Disorder is distinguished from a Nl.ixed Episode by its characteristic early onset (i.e., before age 7 years), chronic rather than episod ic course, lack of relatively d ear onsets and offsets, and the absence of abnormally expansive or elevated mood or psychotic features. Children with AttentionDeficit/ H yperactivity Disorder also sometimes show depressive symptoms such as low self-esteem and frus tration tolerance. If criteria are met for both, Atten tion Deficit/H yperactivity Disorder may be d iagnosed in addition to the Mood Disorder.
Hypomanic Ep isod e
drug of abuse, a medication, or other t reatment ) or a general medical condition (e.g., hyperthyroid ism). Note: Mixed-like episodes th at are dea rly caused by somatic ant idepressant treatment (e .g., medication, electroconvu lsive thera py, light therapy) should not count toward a diagnos is of Bipol ar I Disorder.
Hypomanic Episode
Episo de Features
A H}'pomanic Episode is defin ed as a d istinct period d uring which there is an abnormally and persisten tly elevated, expansive, or irritable mood that lasts at least 4 d ays (Criterion A) . This period of abnormal mood must be accomp anied by a t least three add itional symptoms from a list that incl udes inflated self-esteem or grand iosity (nond elusional), d ecreased need for sleep, p ressLUe of sp eech, fli ght of ideas, d istractibility, increased involvement in goal-di rected activ ities or psychomotor ag itation, and excessive involvement in pleasurab le activities that h ave a high potential for pain ful consequences (Criterion B). If the mood is irritable rather than elevated or expansive, at least fo ur of the above symptoms must be present. This list of additional symp toms is identical to those that define a Manic Episode (see p. 357) excep t that delusions or hallucinations cannot be present. The mood during a Hyp omanic Episode must be d early different fro m the individual' s usual nondepressed mood, and there must be a clear change in functioning that is not characteristic of the individual's usual fu nctioning (Criterion C). Because the changes in mood and function in g must be observable by others (C riterion 0 ), the evaluation o f this criterion will often require interv iewing other in formants (e.g ., fam ily members). History from other informants is particu larly important in the evaluation of adolescents. In con trast to a Man ic Episode, a Hyp omanic Episod e is not severe enough to cau se marked impairment in social or occupationa l fun ctioning or to require hospitalization, and there are n o psychotic featu res (Cri terion E). The change in function in g for some ind ivid u als may ta ke the form o f a marked increase in efficiency, accom plishmen ts, or creativity. However, for others, hypo man ia ca n cause so me social or occu pa tional impairment.
Mood Disorders
The mood disturbance and other symptom s must not be due to the direct physiolog ical effects of a drug of abuse, a medication, other treatment fo r depression (electroconvulsive therapy or light therapy), or toxin exposure. The episode must also not be due to the d irect physiological effects of a general medical condition (e.g., multiple scle.rosis, b rain tumor) (Criterion F). Symptoms Like those seen in a Hypomanic Episode may be due to the d irect effects of antidepressant medica tion, electroconvulsive therapy, ligh t therapy, or medica tion prescribed for o ther general medical conditions (e.g., corticosteroids). Such presentations are not consid ered Hypomanic Episodes and d o not count toward the diagnosis of Bipolar n Disorder. For example, if a person with recurren t Major Depressive Disorder d evelops symptoms of a hypo manic-like episode during a course of antidepressant medica tion, the episode is diagnosed as a Substance-Induced Mood Disorder, Wi th Manic Features, and there is no switch from a diagnosis of Major Depressive Disorder to Bipolar n Disorder. Some evidence suggests that there may be a bipolar "diathesis" in indi viduals who develop manic- or hypomanic-like episod es follow ing somatic treatment for depression . Such individuals may have an increased likelihood of future Manic or H ypoma nic Episodes that are not rela ted to substances or somatic treatments for depression. The elevated mood in a Hypomanic Episode is d escribed as euphoric, unusually good, cheerful, or high. Although the person's mood may have an infectious qua lity for the uninvolved observer, it is recognized as a distinct change from the usual self by those who know the person weU. The expansive quality of the mood djs turbance is characterized by enthusiasm for social, interpersonal, or occupational interactions. Although elevated mood is considered prototypical, the mood disturbance may be irritable o r may alternate between eu phoria and irritability. Characteristically, in nated self-esteem, usually at the level of uncritical self-confidence ra ther than marked grand iosity, is present (Criterion Bl ). There is very o ft en a decreased need fo r sleep (Criterion 82); the person awakens before the usual time with increased energy. The speech of a person with a Hyp omanic Episode is often somewhat louder and more rapid than usu al, but is not typically d iffi cult to interrupt. It may be full of jokes, puns, plays on words, and irrelevancies (Criterion B3). Flig ht of ideas is uncommon and, if present, lasts for very brief periods (Cri terion 84). Distractibility is often present, as evidenced by rapid changes in speech or activity as a resull of responding to various irrelevant external stimuli (Criterion B5). The increase in goal-directed activity may involve planning of, and participation in, multiple activities (Criterion B6) . These activities are often creative and producti ve (e.g.; writing a letler to the editor, clearing up paperwork). Sociability is usually increased, and there may be an increase in sexual activity. There may be impulsive activity such as buying sprees, reckless driving, or foolish business investments (Criterion B7). However, such activities are usua lly organized, are not bizarre, and do not resull in the level of impairment that is characteristic of a Manic Episode.
Hypomanic Episode
367
Course
A Hypomanic Episode typically begins sudd enly, with a rapid escalation of symptoms w ithin a d ay o r two. Episodes may last for several weeks to months and are usually more abrupt in onset and briefer than Major Depressive Episodes. In m any cases, the Hypomanic Episode may be preceded or followed by a Major Depressive Episode. Studies suggest tha t 5%- 15" of individuals with hyp omania will ultimately de/" velop a Manic Episode.
Differential Diagnosis
A Hypomanic Episode must be d istinguished from a Mood Disorder Due to a General Medical Condition . The diagnosis is Mood Disorder Due to a Genera l Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condi tion (e.g., multiple sclerosis, bra in tumor, Cushing's syndmme) (see p. 401). This determination is based o n the history, laboratory fi nd ings, or physical examination. If it is judged that the hypomanic symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded on Axis I (e.g., Bipolar II Disorder) and the general medical cond ition is recorded on Axis III (e.g., myocardial infarction). A Substance-Induced Mood Disorder is distinguished from a Hypomanic Episode by the fact that a substance (e.g., a d rug of abuse, a medica tion, or exposure to a toxin) is judged to be etiologically related to the mood disturbance (see p. 405). Symptoms like those seen in a H}'Poman ic Episode may be precipita ted by a drug of abuse (e.g., hypomanic symptoms that occur only in the context of intoxication w ith cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Intoxication). Symptoms like those seen in a Hypomanic Episode may also be p recipitated by an tidepressant treatment such as m edica tion, electroconvulsive therapy, or light therapy. Such episodes are also d iagnosed as SubstanceInduced Mood. Disorders (e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic f eatures). However, clinical judgment is essential to detennine whether the treatment is truly causal or w hether a primary Hypo manic Episode happened to have its onset while the person was receiving the treatment (see p. 406). Manic Episodes should be distinguished from Hy pomanic Episodes. Although Manic Episod es and Hypomanic Episodes have identical lists of characteristic symptoms, the m ood disturbance in Hypomanic Episodes is not sufficientl y severe to cause marked impainnent in social or occupational fun ctioning or to require hospitalization. Som e Hypomanic Episodes may evolve into full Manic Episodes. Attention-DeficitlHyperactivity Disorder and a Hypomanic Episode are both
Mood Disorders
characterized by excessive activity, impulsive behavior, poor judgment, and denial o f problems. Atten tion-Deficit/ Hyperactivity Disorder is distinguished from a Hypomanic Episode by its characteristic early onset (Le., before age 7 years), chronic rather than episodic course, lack of relatively clear onsets and offsets, and the absence of abnormally expansive or elevated mood . A Hypomanic Episode must be distinguished from eu th ymia, particuJariy in individuals who have been chronically depressed and are unaccustomed to the experience of a nondepressed mood state.
acteristic of the person when not symptomat ic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe e nough to cause marked impairment in social or occupa tiona l fun ctioning, or to necessitate hospitalization, and t here are no psychotic fea tures. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medica l condition (e.g ., hyperthyroidism) . Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light t herapy) should not count toward a diag nosis of Bipola r II Disorder.
Depressive Disorde rs
369 1
Depressive Disorders
Specifiers
If the full criteria are currently met for a Major Depressive Episode, the following specifiers may be used to describe the current clinical stahls of the episode and to de scribe features of the current episode:
370
Mood Disorders
Mild, Moderate, Severe Without Psychotic Features, Severe With Psych otic Features (see p. 411) Chronic (see p. 417) With Catatonic Features (see p. 417) With Melancholic Features (see p. 419) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422)
If the fu ll criteria are not currently met for a Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the Major Depressive Disorder and to describe features of the most recent episode:
In Pa rtial Remission, In Full Remi ssion (see p. 411 ) Chronic (see p. 41 7) With Catatonic Features (see p. 417) With Melancholic Featu res (see p. 419) With Atypical Features (see p . 420) With Postpartum Onset (see p . 422) nle follow ing specifie rs may be used to indica te the pa tte rn of the episodes and the presence of interepisode symptoms for Major Depressive Disorder, Recurrent:
Longitudinal Course Specifiers (With and Without Fullin terepisode Recovery) (see p. 424) With Seasonal Pattern (see p. 425)
Recording Procedures
TIle diagnostic codes for Major Depressive Disorder are selected as follows: 1. The first three digits are 296. 2. The fourth digit is either 2 (if there is only a single Major Depressive Episode) or 3 (if there are recurrent Major Depressive Episodes). 3. If the full cri teria are curren tly met for a Major Depressive Episode, the fifth digit indicates the current severity as follows: 1 for Mild severity, 2 fo r Moderate severity, 3 for Severe Without Psychotic Features, 4 for Severe With Psychotic Features. If the full cri teria are not currently met for a Major Depressive Episode, the fifth dig it indicates the current clinical status of the Major Depressive Disorder as foll ows: 5 for In Partial Remission, 6 for In Full Remission. If the severity of the current episode or the current remission status of the disorder is unspecified, then the fifth digit is O. Other specifiers for Major Depressive Disorder cannot be coded. In recording the name of a diagnosis, terms should be Listed in the following order: Major Depressive Disorder, specifiers coded in the fourth digit (e.g., Recurrent), specifiers coded in the fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial Remission), as many specifiers (without codes) as apply to the current or most recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as man}'
371
specifi ers (without codes) as apply to the course of episodes (e.g ., With Full Interepi sode Recovery); for example, 296.32 Major Depressive Disorder, Recurrent, Moderate, With Atypical Features, With Seasonal Pattern, With Fullinterepisode Recovery.
Mood Disorders
Prevalen ce
Studies of Major Depressive Disorder have reported a w ide range of values for the proportion of the adult population with the d isorder. The lifetime ris k for Major Depressive Disorder in community samples has varied from 10% to 25% for women and from 5% to 12% for men . The point prevalence of Major Depressive Disord er in adults in com munity samples has varied fro m 5% to 9% for women and ITom 2% to 3% fo r men . The p revalence rates for Major Depressive Dis order ap pear to be unrelated to elhnicity, education, income, o r marital s tatus.
Cou rse
Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data s ugges t that the age at onset is d ecreasing for those born more recently . The course of Major Dep ressive Disorder, Recurrent, is variable. Some people have isolated ep isodes that are separated by m any years w ithout any depressive symptoms, w hereas others h ave dus ters of episodes, and still others have increa singly frequent episodes as they g row older. Some evidence s ugges ts that the periods of remission generally las t longer early in the course of the d is order. The number of prior episod es predicts the likelihood of developing a su bsequent Major Depressive Episod e. At leas t 60% of individuals with Major De pressive Disorder, Single Ep isod e, can be expected to have a second episode. Individuals who have had two ep isodes have a 70"10 chance of having a third , and indiv iduals w ho have had three episodes have a 90% chance o f h aving a fourth. Abo ut 5%- 10 of individuals with ;', Major Depressive Disorder, Sing le Episode, subsequently develop a Manic Ep isode (Le., d evelop Bipolar I Disorder). Major Depressive Epis od es may end com p letely (in about h vo-thirds of cases), or only partially or not at all (in abou t one-third of cases). For ind ividuals w ho have ani}' partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern o f partial interep isode recovery. The longitud ina l course specifiers With FulJ Intere pisode Recovery and Without Fullin tere pisod e Recovery (see p . 424) may therefore have prognostic value. A number of individuals have pre-
373
existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, Single :pisode. Some evidence suggests that these individuals are more likely to have add itional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing trea tment to attain and ma intain a more thorough and longer-lasting euthymic s tate. Follow-up naturalistic s tudies suggested that 1 year after the diagnosis of a Major Depressive Episode, 40% of individuals s till have symptoms that are sufficien tly severe to meet criteria fo r a full Major Depressive Episode, roughly 20% con tinue to have some symptoms that no longer meet fuJi criteria for a Major Depressive Episode (i.e., Major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episod es. Episodes of Major Depressive Disorder often foUow a severe psychosocial s tressor, such as the death of a loved one or divorce. Studies s ugges t that psychosocia l events (slressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of s ubsequent episodes. Chronic general m edical conditions and Subs tance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder. It is difficult to predict whether the firs t episode of a Major Depressive Disorder in a young person w ill ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe d epression, especially with psychotic features and psychomotor retardation, in a young person without prepuberta l psychopathology is more likely to predict a bipolar course. A famil y history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.
Familial Pattern
Major Depressive Disorder is 1.5--3 times more common among first -degree biological relatives of persons with this disorder than among the general population. There is evidence for an increased risk of Alcohol Dependence in adult firs t-degree biological relatives, and there may be an increased incidence of an Anxiety Disorder (e.g., Panic Di sorder, Social Phobia) or Attention-Deficit / Hyperactivity Disorder in the chi ldren of adults with Major Depressive Disorder.
Differential Diagnosis
See the "Differential Diagnosis" section for Major Depressive Episode (p. 354). A hi story of a Manic, Mixed, or Hypoman ic Epi sode precludes the d iagnosis of Major Depressive Disorder. The presence of Hypomanic Episodes (without any history of Manic Episodes) indicates a diagnosis of Bipolar II Disorder. The presence of Manic or Mixed Episodes (with or without Hypomanic Episodes) indicates a diagnosis of Bipolar I Disorder. Major Depressive Episodes in Major Depressive Disorder must be dis tinguis hed from a Mood Disord er Due to a General Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition if the mood dis turbance is judged to be
374
Mood Disorders
pressive symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded on Axis I (e.g., Major Dep ressive Disorder) and the general medica l condition is recorded on Axis ill (e.g., myocardial infarction). This wou ld be the case, fo r example, if the Major Depressive Episode is considered to be the psychological consequence of hav ing the general medical condition or if there is no etiological relationship between the Ma jo r Depressive Episode and the general medical condition . A Substance-Induced Mood Disord er is dis tinguished from Major Dep ressive Episod es in Major Depressive Disorder by the fact tha t a s ubs tance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologicaUy related to the mood disturbance (see p . 405). For example, depressed mood that occurs only in the con text of w ithd rawal from cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Dep ressive Featu res, With Onset During Withdrawal. Dysthymic Disorder and Major Depressive Disorder are differentiated based on severity, chronicity, and persistence. In Majo r Depressive Disorder, the depressed mood mus t be present for most of the day, nearly every day, for a period of at leas t 2 weeks, whereas Dysthymic Disorder must he present for more days than not over a period of at leas t 2 yea rs. llle differen tia l diagnosis between Dys thymic Disorder and Major Depressive Disorder is made particularly difficult by the fa ct that the two disorders share similar symptoms and that the differences between them in onset, dura tion, persis tence, and severity are not easy to evaluate retrospectively. Usually Major Depressive Disorder consis ts of one or more discrete Major Dep ressive Episodes that can be distinguished from the person's us ual functioning, whereas Dysthymic Disorder is cha racterized by ch ronic, less severe depressive symptoms that have been present fo r many years. If the initial onset of chronic depressive symptoms is of sufficien t severity and number 10 meet criteria for a Major Depressive Episode, the diagnosis would be Major Depressive Disorder, Chronic (if the criteria are still met), or Major Depressive Disorder, In Partial Remission (if the criteria are n o longer met). The diagnosis of Dysthym ic Disorder is made follow ing Major Depressive Disorder only if the Dys thymic Disorder was established prior to the fi rst Major Depressive Episode (i.e., no Major DepresSive Episodes during the first 2 years of d ysthymiCsym ptoms), or if there has been a full remission of the Major Depressive Episode (i.e., lasting at leas t 2 months) before the onset of the Dysthymic Disorder. Schizoaffective Disorder differs from Major Depressive Disorder, With Psychotic Features, by the requirement that in Schizoaffective Disorder there mus t be at least 2 weeks of delusions or hallucinations occurring in the absence of p rominent mood symptoms . Depressive symptoms may be present du ring Sch izophreni a, Delusional Disorder, and Psychotic Disorder Not Otherwise Specified. Most commonly, such depressive symptoms can be considered associated features of these disorders and do not merit a separate diagnosis. However, when the depressive symptoms meel full criteria for a Major Depressive Episode (or are of particular clinical significance), a d iagnosis of Depressive Disorder Not Otherwise Specified may be made in addition to the d iagnosis of Schizophren ia, Delu sional Disorder, or Psychotic Disorder Not Othenvise Specified. Schizoph renia, Catatonic Type, may he d ifficult to dis ting uish from
375
Major Depressive Disorder, With Ca tatonic Features. Prior his tory or family history may be helpful in making this dis tinction. In elderly individuals, it is often difficult to determine w hether cognitive symptoms (e.g., disorienta tion, apathy, difficulty concentrating, memory loss) are better accounted for by a dementia o r by a Major Dep ressive Episode in Major Depressive Disorder. This differential d iagnosis may be informed by a thorough genera l medical evaluation and consideration of the onset of the dis turbance, tempora l sequencing of depressive and cognitive symptoms, course of illness, and treatment response. The premorbid s tate of the individual may help to differentiate a Major Depressive Disorder from dementia. In dementia, there is usually a premorbid his tory o f declining cognitive function, w hereas the individual with Major Depressive Disorder is much more likely to have a relatively nom,al premorbid s tate and abrupt cognitive decline associated w ith the depression.
B. The Ma jor Depressive Episode is not better accou nted for by Schizoatfective Disorder and is not superimposed on Schizophrenia, Schizophren iform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episod e (see p. 362), a Mixed Episode (see p. 365), or
a Hypoman ic Episode (see p. 36B). Note: This exclusion does not apply if all of the man ic-like, mixed-like, o r hypoma nic-l ike episodes are substa nce or t reatment induced or are due to the direct physiological effects of a general medical condit ion. If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or fea t ures: Mild, Moderate, Severe Without Psychotic Feature s/Severe With Psychotic Features (see p. 41 t) Chronic (see p. 417) With Catatonic Features (see p. 417) With Melancholic Features (see p. 419) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422) If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode: In Partial Remission, In Full Remission (see p. 41 t ) Chronic (see p. 417) With Catatonic Feature s (see p. 417) With Melancholic Features (see p. 419) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422)
376
Mood Disorde rs
C. There has never been a Manic Episode (see p. 362). a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypoma nic-like episodes are substance or treatment induced or a re due to the direct physiologica l eff ects of a general med ica l condition.
If the full criteria are currently met for a Major Depressive Episode, specify its curre nt clinical status and/or features: Mild, Moderate, Severe Without Psychotic FeaturesJ Severe With Psychotic Features (see p. 411) Chronic (see p. 417) With Ca tatonic Features (see p. 41 7) With Melancholic Features (see p. 419) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422) If the full criteria a re not (urrently met fo r a Major Depressive Episode, specify the (urrent clinical status of the Major Depressive Disorder or features of the most recent episode: In Partial Remission, In Full Remission (see p. 411) Chronic (see p. 417) With Catatonic Features (see p. 417) With Melancholic Features (see p. 419) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422)
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424) With Seasonal Pattern (see p. 425)
300.4
Diagnostic Feat ures
Dysthymic Disorder
The essential feature of Dysthymic Disorder is a chronically depressed mood that occu rs for most of the day more days than no t for at least 2 years (Criterion A) . Individ-
300.4
Dysthymic Disorder
377
uals with Dys thymic Disorder describe their mood as sad or "down in the dumps." In children, the mood may be irritable rather than depressed, and the required minimum dLUation is only 1 year. DLUing periods of depressed mood, at least h \'o of the foUowing additional symptoms are present: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-es teem, poor concentration or difficulty making decisions, and feelings of hopelessness (Criterion B). individuals may note the prominent presence of low interes t and self-criticism, often seeing themselves as uninteresting or incapable. Because these symptoms have become so much a part of the individual's day-to-day experience (e.g ., "I've always been this way," "That's jus t how I am"), they are often not reported unless directly asked about by the in terv iewer. DLUing the 2-year period (1 year for children or adolescents), any symptom-free intervals las t no longer than 2 months (Criterion C). The diagnosis of Dysthymic Disorder can be made only if the initial 2-year period of d ysthymic symptoms is free of Major Depressive Episodes {Criterion D). If the chronic depressive symptoms include a Major Depressive Episode during the initial 2 years, then the diagnosis is Major Depressive Disorder, Chronic (if full criteria for a Major Depressive Episode are met), or ~'I ajor Depressive Disorder, In Partial Remission (if full criteria for a Major Depressive Episode are not cLUrently met). After Ule initial 2 years of the Dysthymic Disorder, Major Depressive Episodes may be superimposed on the Dysthymic Disorder. In such cases ("double depression "), both Major Depressive Disorder and Dysthymic Disorder are diagnosed. Once the person returns to a dysthymic baseline (I.e., criteria for a Major Depressive Episode are no longer met but d ysthymic symptoms persis t), only Dysthymic Disorder is diagnosed. The diagnosis of Dysthymic Disorder is not made if the individual has ever had a :"'Ianic Episode (p o357), a Mixed Episode (p . 362), or a H ypomanic Episode (po 365) or if criteria have ever been met for Cyclothymic Disorder (Criterion E). A separa te diagnosis of Dysthymic Disorder is not made if the depressive symptoms occur exclusively during the course of a chronic Psychotic Disorder, such as Schizoph renia or Delusional Disorder (Criterion F), in w hich case they are regarded as associated features of these disorders. Dysthymic Disorder is also not diagnosed if the dis turbance is d ue to the direct physiological effects of a s ubs tance (e.g., alcohol, antihypertensive medications) or a general medical condition (e.g., hypothyroidis m, Alzheimer's disease) (Criterion G). The symptoms mus t cause clinically significant dis tress or impairmen t in social, occupational (or academ ic), or other important areas of fun ctioning (Criterion H).
Specifiers
Age at onset and the characteristic pattern of symptoms in DysthymiC Disorder may be indicated by using the foll owi.ng specifiers: Early Onset. This specifier should be u sed if the onset of the d ysthymic symptoms occurs before age 21 years. Such individuals are more likely to devclop subsequent Major Depressive Epi sodes. Late Onset. This specifier should be used if the onset of the d ysthymic symptoms occurs at age 21 or older. With Atypical Features. This s pecifier should be used if the pattern of symp-
378
300.4
Prevalence
The lifetime prevalence of Dysthymic Disorder (with or without superimposed Major Depressive Disorder) is approximately 6%. The point prevalence of Dysthym ic Disorder is approximately 3%.
Course
Dysthymic Disorder often has an early and insidious onset (i.e., in childhood, adolescence, or early adult life) as well as a duonic course. In clinical settings, individuals with Dysthymic Disorder usually have superimposed Major Depressive Disorder, which is often the reason for seeking treatment. If Dysthymic Disorder precedes the onset of Major Depressive Disorder, there is less likelihood that there will be spontaneous full interepisode recovery between Major Depressive Episodes and a greater likeWlOod of having more frequ ent subsequent episodes. Although the spontaneous remission rate for Dysthy mic Disorder may be as low as 10% per yea r, evidence suggests the outcome is significantly better w ith active trea tment. The trea~ed course of Dysthymic Disorder appears similar to that of other Depressive Disorders, whether or not there is a superimposed Major Depressive Disorder.
Differential Diagnosis
See the "Differential Diagnosis" section for Major Depressive Disorder (p. 373). The differential diagnosis between Dysthymic Disorder and Major Depressive Disorder is made particularly difficult by the facts that the two disorders share similar symptoms and tha t the differences between them in onset, duration, persistence, and severity are not easy to evaluate retrospectively. Usua lly Major Depressive Disorder consists of one or more discrete Major Depressive Episodes that can be distinguished from the person's usual functioning, whereas Dysthym ic Disorder is characterized by chronic, less severe d epressive symptoms that have been present for many years. \-Vhen Dys thymic Disorder is of many years' duration, the mood d isturbance may not be easily distinguished from the person's " usual" fWlCtioning. U the initial onset of chronic depressive symptoms is of sufficient severity and number to meet full criteria fo r a Major Depressive Episode, the diagnosis would be Major Depressive Disorder, Chronic (if the full criteria are st ill met), or Major Depressive Disorder, In Partial Remission (if the full criteria are no longer met). The diagnosis of DysthymiC Disorder can be made following rvlajor Depressive Disorder ani}' if the Dysthymic Disorder was established prior to the first Major Depressive Episode (i.e., no Major Depressive Episodes during the first 2 years o f d ysthymic symptoms), or if there has been a htll remission of the Major Depressive Disord er (i.e., lasting at least 2 months) before the onset of the Dysthymic Disord er.
Mood Disorders Depressive symptoms may be a common associated. feature of chronic Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, Delusional Disorder). A separate diagnosis of Dysthym.ic Disorder is not made if the symptoms occur onl y during the course of the Psychotic Disorder (including residual phases). Dysthymic Disorder mus t be distinguis hed from a Mood Disorder Due to a General Medical Co ndition. The diagnosis is Mood Disorder Due to a General Medical Condition, With Depressive Feahues, if the mood dis turbance is judged to be the direct physiological consequence of a specific, us ually chronic, general med ical condition (e.g., multiple sclerosis) (see p. 401). This determination is based on the his tory, laboratory findin gs, or physical examination. If it is judged that the depressive symptoms are not the direct physiological consequence of the general medical condition, then the p rimary Mood Disorder is recorded on Axis I (e.g., Dysthymic Disorder) and the general medical condition is recorded on Axis III (e.g., diabetes mellitus). This would be the case, for exam p le, if the d epressive symptoms are considered to be the p sychological consequence of having a chronic general medica l condition or if there is no etiologica l relationship between the depressive symptoms and the general medical condition. A Substance-Induced Mood Disorder is distinguished from a Dysthymic Disorder by the fa ct that a subs tance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically relaled to the mood disturbance (see p.405). Often there is evid en ce of a coexisting personality disturbance. When an individual's presentation meets the cri teria for both Dysthymic Disorder and a Personality Disorder, both d iagnoses are g iven.
subjective account or observation by othe rs, for at least 2 years. Note: In children and adolescents, mood ca n be irritable and duration must be at least 1 year. 8. Presence, while depressed, of two (or more) of the following:
(1 )
poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-erteem poor concentration or difficulty making decisions feelings of hopelessness
C. During the 2year period (1 year for children or adolescents) of the dirturbance, the per
son has never been without the symptoms in Criteria A and 8 for more than 2 months at a time. D. No Major Depressive Episode (see p. 356) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Ma jor Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
311
F. The disturbance does not occur exclusively during the co urse of a chro nic Psychotic Disorder, such as Schizophrenia or Delusi o nal Disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a med ication) o r a general medical co nd ition (e.g ., hypothyroidism).
H. The symptoms cause cl inically significant d istress or impa irment in social, occupation-
Specify if:
Early Onset: if onset is before age 21 years Late Onset: if onset is age 21 years or o lder
311
The Depressive Disorder Not Otherwise Specified category includes d isorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adju stment Disorder With Depressed Mood (see p. 679), or Adjustment Disorder With Mixed Anxiety and Depressed Mood (see p. 680). Sometimes depressive symptoms can present as part o f an Anxiety Disorder ot O thenvise Specified (see p. 484). Examples of Depressive Disorder 01 Otherwise Specified include 1. Premenstrllal d ysphoric disorder: in most menstrual cycles during the past year, symptoms (e.g., m arkedly depressed mood , marked anxiety, marked affective lability, d ecreased interest in activ ities) regularly occurred during the last week of the luteal phase (and remitted w ithin a few days of the onset of menses). These symptoms must be severe enough to markedly in terfere with work, school, or usual acti vities and be entirely absent for at least 1 week postmenses (see p. 771 for suggested research criteria). 2. Minor d epressive disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the five items reqUired for Major Depressive Disorder (see p. 775 for suggested research criteria).
382
Mood Disorders
3. Recurrent brief depressive disorder: depressive episodes lasting from 2 days up to 2 weeks, occurring at leas t once a month for 12 months (n ot associated with the mens trual cycle) (see p. 778 for s uggested research criteria).
4. Postpsychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs du ring the residual phase of Schizophrenia (see p . 767 for su ggested research criteria).
5. A Major Depressive Episode superimposed on Delusiona l Disorder, Psychotic Disorder Not Othen vise Specified, or the aclive phase of Schizophrenia. 6. Situa tions in w hich the clinician has conduded that a depreSSive disorder is present but is unable to detennine whether it is primary, due to a general medical condition, o r substance induced.
Bipolar Disorders
This section includes Bipolar I Disorder, Bipolar " Disorder, Cyclothymia, and Bipola r Disorder Not Othenvise Specified. There are six separa te criteria sets fo r Bipolar I Disorder: Single Manic Episode, Most Recent Episode Hypomanic, Most Recent Episode Manic, Most Recent Episode rvlixed, Most Recent Episode Depressed, and Most Recent Episode Unspecified. Bipolar r Disorder, Single Manic Episode, is used to describe individuals who are having a first episode of mania . The remaining criteria sets are used to specify the nature of the current (or most recent) episode in individuals w ho have had recurrent mood episodes.
Bipolar I Disorder
Diagnostic Features
The essential featu re of Bipola r I Disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes (see p. 357) or ~'1i xed Episodes (see p. 362). Often individuals have also had one or more Major Depressive Episodes (see p. 349). Episodes of Substance-Induced Mood Disorder (due to the di rect effects of a medication, other soma tic treatments for depression, a d rug of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Cond ition do not count toward a diagnosis of Bipolar I Disorder. In addition, the episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizoph reniform Disorder, Delusional Disorder, or Psychotic Disorder NotOthenvise Specified . Bipolar I Disorder is subclassifi ed in the fourth digit of the code according to whether the individual is experiencing a fi rst episode (Le., Single Manic Episode) or whether the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode or an interval behven episodes of at least 2 months without manic sym ptoms. A shift in polarity is defined as a clinical course in which a Major Depressive Episode evolves into a Manic Episode o r a Mixed Episode or in which a Manic Episode or a Mixed Episode evolves into a Major Depressive Episode. In contrast, a Hypomanic Episode that evolves into a Manic Episode or a Mixed Epi-
Bipolar I Disorder
sode, or a Manic Episode that evolves into a Mixed Episode (or vice versa), is considered to be only a single episode. For recurrent Bipolar I Disorders, the nature of the current (or m ost recent) episode can be sp ecified (Most Recent Episode Hyp omanic, Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, Most Recent Episode Unspecified ).
Specifiers
If the full criteria are currently met for a Manic, Mixed, or Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the episode and to describe features of the current episode: Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features (see p. 411) With Catatonic Features (see p. 417) With Postpartum Onset (see p. 422) If the full criteria are not currently met for a Manic, Mixed or Major Depressive Episode, the following specifiers may be used to describe the current clinical sta tus of the Bipolar I Disorder and to describe features of the most recent episode: In Partial Remission, In Full Remission (see p. 411 ) With Catatonic Features (see p. 41 7) With Postpartum Onset (see p. 422) If criteria are currently met for a Major Depressive Episode, the follow ing may be used to describe features of the current episode (or, if criteria are not currently met but the most recent episode of Bipolar I Disorder was a Major Depressive Episode, these specifiers apply to that episode): Chronic (see p. 41 7) With Melancholic Features (see p. 41 9) With Atypical Features (see p. 420) The following specifiers can be used to indicate the pattern of episodes: longitudinal Course Specifiers (With and Without Fullinterepisode Recovery) (see p. 424) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425) With Rapid Cycling (see p. 427)
Recording Procedures
The diagnostic codes for Bipolar I Disorder are selected as follows:
1. The first three digits are 296. 2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth digit indicates the nature of the current episode (or, if the Bipolar I Dis-
384
Mood Disorders
order is currently in partial or full remission, the nahlre of the most recent episode) as follows: 4 if the current or most recent episode is a Hypomanic Episode or a Manic Episode, S if it is a Major Depressive Episode, 6 if it is a Mixed Episode, and 7 if the current o r most recent episode is Unspecified. 3. The fifth digit (except for Bipolar I Disorder, Most Recent Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the severit}' of the current episode if fuU crite ria are met for a Manic, Mixed, or Major Depressive Episode as follows: 1 for Mild severity, 2 for Moderate severity, 3 for Se,'ere Without Psychotic Features, 4 for Severe With Psychotic Features. If full criteria are not met for a Manic, Mixed, or Major Depressive Episode, the fifth digit indicates the current clinical status o f the Bipolar I Disorder as foll ows: 5 for In Partial Remission, 6 for In Full Remission. If current severity or clinical status is unspecified, the fifth digit is O. Other specifiers for Bipolar I Disorder cannot be coded. For Bipolar I Disorder, Most Recent Episode Hypomanic, the fifth d igit is always O. For Bipolar Disorder, Most Recent Episode Unspecified, there is no fifth dig it. In recording the name of a diagnosis, terms should be listed in the foll owing order: Bipolar I Disorder, specifiers coded in the fourth digit (e.g., Most Recent Episode Manic), specifiers coded in the fifth dig it (e.g., Mild , Severe With Psychotic Features, In Partial Remission), as many specifiers (without codes) as apply to the current or most recent episod e (e.g., With Melancholic Featu res, With Postpartum Onset), and as many specifiers (without codes) as apply to the course of episodes (e.g., With Rapid Cycling); for example, 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, With Melancholic Features, With Rapid Cycling. Note that if the single episode of Bipolar I Disorder is a Mixed Episode, the diagnosis would be indicated as 296.0x Bipolar I Disorder, Single Manic Episode, lvtixed.
Bipolar I Disorder
385
Imaging studies comparing groups of indi\'iduals with Bipolar I Disorder with groups with Major Depressive Disorder or groups without any Mood Disorder tend to show increased ra tes of right~hemisp h eric lesions, or bilateral subcortical or p eri ~ ventricular lesions in those w ith Bipolar I Disorder.
Associated physical examination findings and general medical conditions. An age at onset for a first Manic Episode after age 40 years should alert the clinician to the possibili ty that the symptoms may be due to a general medical condition or sub~ stance use. Curren t or pa st hypothyroidism or labora tory evidence of mild thyroid hypofunction may be associated with Rapid Cycling (see p . 427). In 'a ddition, hyper~ thyroid ism may precipitate o r worsen ma nic symptoms in individuals with a preex~ isting Mood Disorder. However, hyperthyroidism in individuals without p reexis ting Mood Disorder does not typically cause manic symptoms.
Prevalence
The lifetime preva lence of Bipolar I Disorder in community samples has varied from 0.4% to 1.6%.
386
Co urse
Mood Di sorde rs
Average age at onset is 20 for both men and women. Bipolar 1 Disorder is a recurrent disorder-more than 90% of individuals who have a single Manic Episode go on to have future episodes. Roughly 60'Yo-700/0 of Manic Episodes occur immediately before or after a Major Depressive Episode. Manic Episodes often precede or follow the Major Dep ressive Episodes in a cha racteristic pattern for a particular p erson. The number of lifetime episodes (both Manic and Major Dep ressive) ten ds to be higher for Bipolar I Disorder compared w ith Major Depressive Disorder, Recurrent. Studies of the course of Bipola r I Disorder prior to lithium maintenance treatmen t s uggest that, on average, four episodes occur in 10 years. The inten' al between episodes tends to decrease as the individual ages. There is some evidence that changes in sleep-wake schedule such as occur durin g time zone changes or sleep deprivation may precipitate or exacerbate a Manic, Mixed, or Hypomanic Episode. Approximately 5%-15% o f individuals with Bipolar I Disorder have multiple (four or more) mood episodes (Major Depressive, Manic, Mixed, o r Hypomanic) that occur within a given year. U this pattern is present, it is noted b y the specifier With Rapid Cycling (see p. 427). A rapid-cycling pa ttern is associated with a poorer prognosis. Although the majority of individuals with Bipolar I Disorder experience significant symptom reduction behveen episodes, some (20%- 30%) continue to display mood lability and other residual mood symptoms. As many as 60% experience chronic interpersonal or occupational difficu lties beh\feen acute episodes. Psychotic symptoms may develop after days o r weeks in what was previously a non psychotic Manic or Mixed Episode. When an individual has Manic Episodes with p sych otic features, subsequent Manic Episodes are more likely to h ave psychotic features. incomplete interepisode recovery is more common when the curren t episode is accompanied by mood-incongruent psychotic features.
Fa milial Pattern
First-degree biological relatives of individuals w ith Bipolar I Diso rder have elevated rates of Bipolar I Disorder (4%-24%), Bip olar II Disorder (1%- 5%), and Major Dep ressive Disord er (4%-24%). Those individuals w ith Mood Disorder in their first-degree biological relatives are more likely to have an earlier age at onset . Twin and adoption studies provide strong evidence of a genetic influence for Bipolar 1 Disorder.
Differential Diagnosis
Major Depressive, Manic, Mixed, and HypomaniC Episodes in Bipolar I Disorder must be distinguished from episodes of a Mood Disorder Due to a Gen eral Medical Condition. The diagnosis is Mood Disorder Due to a General Medical Condition for episodes that are judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidism) (see p. 401 ). This determination is based on the history, laboratory findings, or physical examination. A Sub stance-Induced Mood Disorder is d istinguished from Major Depressive, Manic, or Mixed Episodes that occur in Bipolar I Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the mood d isturbance (see p. 405). Symptoms like those seen in a Manic,
387
Mixed, or Hypomanic Episode may be part of an intoxication with or withdrawal from a drug of abuse and should be diagnosed as a Substance-Induced Mood Disorder (e.g., euphoric mood that occurs only in the context of intoxication with cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Intoxication). Symptoms like those seen in a Manic or Mixed Episode may also be precipi tated by antidepressant treatment SUdl as medication, electrocon\'ulsive therapy, or light therapy. Such episodes may be diagnosed as a SubstanceInduced Mood Disorder (e.g ., Amitrip tyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features) and would not count toward a diagnosis of Bipolar I Disorder. However, when the substance U5e or medication is judged not to fully account for the episode (e.g ., the episode continues for a considerable period autonomously after the substance is discon tinued), the episode would count toward a diagnosis of Bipolar TDisorder. Bipolar I Disorder is distinguished from Major Depressive D iso rder and Dysthymic D isord er by the lifetime his tory of at least one Manic or Mixed Episode. Bipolar I Disorder is distinguished from Bipolar II D isorder by the presence of one or more Manic or Nlixed Episodes. When an individual previously diagnosed with Bipolar II Disorder develops a Manic or Mixed Episode, the diagnosis is changed to Bipolar I Disorder. In Cyclothymic D isorde r, there are numerous periods of hypomanic symptoms that do not meet criteria for a Manic Episode and periods of depressive symptoms that d o not meet symptom or duration criteria for a Major Depressive Episode. Bipolar I Disorder is d istinguished from Cyclothymic Disorder by the presence of one or more Manic or Mixed Episodes. If a Manic or Mixed Episode occurs after the first 2 years of Cyclothymic Disorder, then Cyclothymic Disorder and Bipolar I Disorder may both be d iagnosed. The differential diagnosis between Psychotic D isorders (e.g., Schizoaffective Disorder, Schizophrenia, and Delusional Disorder) and Bipola r I Disorder may be difficult (especially in adolescents) because these disorders may s hare a number of presenting symptoms (e.g., grandiose and persecutory delusions, irritability, agita tion. and catatonic symptoms). particularly cross-sectionally and early in their course. In contrast to Bipolar I Disorder, Schizophrenia, Schizoaffective Disorder. and Delusiona l Disorder are all characterized by periods of p sychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history . Manic and depressive symptoms may be present during Schizophrenia, Delusional Disorder, and Psychotic Disorder Not Otherwise Specified, but rarely with sufficient number, duration, and pervasiveness to meet criteria for a Manic Episode or a Major Depressive Episode. However, when full criteria are met (or the symptoms are of particular clinical significance), a diagnosis of Bipolar Disorder Not O thenvise Specifi ed may be made in addition to the diagnOSiS of Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. If there is a very rapid alternation (over days) behveen manic symptoms and depressive symptoms (e.g., several days of purely manic symptoms followed by several days of purely depressive symptoms) that do not meet minimal duration criteria for a Manic Episode or Major Depressive Episode, the diagnosis is Bipolar Disorder No t Othenvise Specified .
388
M ood Disorders
sodes.
Note: Recurrence is defined as either a change in polarity from depression or an
interval of at least 2 months without manic symptoms. B. The Manic Episode is not better accounted for by Sch izoaffective Disorder and is no
superim posed on Schizophrenia, Schizo ph reniform Disorder. Delusional Disorder, or Psychotic Disorder Not Ot herwise Specified.
Specify if:
Mixed:
If the fu ll cri teria are currently met for a Mani c, Mixed. or Major Depressive EpisodE specify its current clinical status andlor features:
Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 4 10) With Catatonic Features (see p. 4 17) With Postpartum Onset (see p. 422) If the full criteria are no t current ly met for a Manic, Mixed, o r Major Depressive Episode, specify the curre nt clinica l status of the Bipolar I Disorder or featu res of the most recent episode: In Partial Remission, In Full Remission (see p. 410) With Catatonic Features (see p. 41 7) With Postpartum Onset (see p. 422)
Diagnostic criteria for 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic
A. Currently (or most recently) in a Hypomanic Episode (see p. 368).
B. There has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).
C. The mood symptoms ca use clinically sig nificant distress or impairment in social, occupational, o r other important areas of fu nctioning.
D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder. Delusional Diso rder, or Psychotic Disorder Not Otherwise Specified.
Specify:
longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424) With Seasonal Pattern (applies o nly tothe patte rn of Major Depressive Episodes) (see p. 425) With Rapid Cycling (see p. 427)
Bi polar I Disorde r
If the full criteria are currently met for a Man ic Episode, specify its current clinical status and/or features : Mild, Moderate, Severe W ithout Psychotic Features/Severe With Psychotic Features (see p. 413) With Catatonic Features (see p. 417) With Postpartum Onset (see p. 422) If the full criteria are not currently met for a Ma nic Episode, specify the curre nt cl inica l status of the Bipolar I Disorder and/or features of the most recent Manic Episode: In Partial Remission, In Full Remission (see p. 414) With Catatonic Features (see p. 417) With Postpartum Onset (see p. 422)
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424) With Seasonal Pattern (appl ies o n ly tathe pattern o f Major Depressive Episodes) (see p. 425) With Rapid Cycling (see p. 427)
390
Mood Disorders
Diagnostic criteria for 296.6x Bipolar I Disorder, Most Recent Episode Mixed
A. Currently (or most recently) in a Mixed Episode (see p. 365) .
B. There has previously been at least one Major Depressive Episode (see p. 356), Manic Episode (see p. 362), or Mixed Episode (see p. 365).
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffec
t ive Disorder and are not superimposed on Schizophrenia, Schi2ophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
If the full criteria are currently met for a Mixed Episode, specify its current clinical status andlor features :
Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 415) With Catatonic Features (see p. 417) With Postpartum Onset (see p. 422)
If the full criteria are not currently met for a Mixed Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Mixed Episode;
In Partial Remission, In Full Remission (see p. 416) With Catatonic Features (see p. 4 17) With Postpartum Onset (see p. 422)
Specify:
Longitudinal Course Specifiers (W ith and Without Interepisode Recovery) (see p. 424) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425) With Rapid Cycling (see p. 427)
Bipolar I Disorder
391
Diagnostic criteria for 296.5x Bipolar I Disorder, Most Recent Episode Depressed
A. Currently (or most recently) in a Major Depressive Episode (see p. 356). B. Th ere has previously been at least one Manic Episode (see p. 362) or Mixed Episode (see p. 365).
C. The mood episodes in Crit eria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, De lusional Disorder. or Psychotic Disorder Not Otherwise Specified .
If the full criteria are currently me t fo r a Major Depressive Episode, specify its current cli nical stat us andlor features: Mild, Moderate. Severe Without Psychotic Features/Severe With Psychotic Features (see p. 411 ) Chronic (see p. 417) With Catatonic Features (see p. 417) With Melancholic Features (see p. 41 9) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422) If the full criteria are not currently met for a Major Depressive Episode. specify the current clinical stat us of the Bipolar I Diso rder andlor features of the most recent Major Depressive Episode: In Partial Remission, In Full Remission (see p. 411 ) Chronic (see p. 417) With Catatonic Features (see p. 417) With Melancholic Features (see p. 41 9) With Atypical Features (see p. 420) With Postpartum Onset (see p. 422)
Specify:
Longitudinal Course Specifiers (With and Without Interepisode Recovery) (see p. 424) With Seasonal Pattern (applies only t o the pattern of Major Depressive Episodes) (see p. 42S) With Rapid Cycling (see p. 427)
C. The mood symptoms cause clinically significant distress or impa irment in social, occupational, or other important areas o f fu nctioning . D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed o n Schizophrenia, Schizophreniform Disorder, Delusio nal Disorder, or Psychotic Disorder Not Ot he rwise Specified . E. The mood symptoms in Criteria A and 8 are not due to the d irect physiological effects o f a substance (e.g., a drug of abuse, a medication, or other t reatment) or a general medical cond itio n (e.g., hy perthyroidism).
Specify:
(see p. 424) With Seasonal Pattern (appl ies o nly to the pattern of Major Depressive Episodes) (see p. 425) With Rapid Cycling (see p. 427)
296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic Episodes)
Diagnostic Features
The essential feature of Bipolar n Disorder is a clinical course that is characterized b)' the occurrence of one or more Major Depressive Episodes (Criterion A) accompanied by at least one Hyp omanic Episode (Criterion B). Hypomanic Ep isodes shouJd not be confused with the several days of euthy mia that may follow remission of a Major Dep ressive Episod e. The presence of a Manic or Mixed Episode precludes the diagnosiS of Bipolar n Disorder (Criterion C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a medication, other sOmatic treatments for depression, drugs o f abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not COWlt toward a diagnOSiS of Bipolar Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Sp ecified (Criterion D). The symptoms must cause clinically significant distress or impai rment in social, occupational, or oth-
296 .89 Bipolar II Disorder (Recu rre nt Major Depressive Ep isodes Wit h Hypomanic Episodes)
393
er important a reas of hmctioning (Criterion E) . In some cases, the H ypomanic Epi sodes themselves do not cause impairment. Instead, the impairment may result from the Major Depressive Episodes or from a chronic pattern of unpredictable mood epi sodes and fluctuating unreliable interpersonal or occupational hmctioning. lndividuals with Bipolar II Disorder may not view the Hypomanic Episodes as pathological, although others may be troubled by the individ ual's erratic behavior. Often individuals, particularly when in the midst of a Major Depressive Episode, d o not recall periods of hypomania w ithout re minders from close friends or relatives. Information from o ther informants is ohen critical in es tablishing the diagnosis of Bipolar II Disorder.
If the full cri teria are currently met for a Major Depressive Episode, the following
specifiers may be used to describe the current clinical s tatus of the episode and to de scribe features of the curre nt episode:
Mild, Mode rate, Severe W ithou t Psychotic Features, Severe W ith Psycho tic
Features (see p . 411) Ch ronic (see p. 41 7) With Catatonic Features (see p . 417) With Melancholic Features (see p . 419) Wi th Atypical Features (see p. 420) With Postpartum O nset (see p. 422)
If the fuJI criteria are no t curre ntly met for a H yp omanic or Major Depressive Epi
sode, the following specifiers may be used to d escribe the current clinical s tatus of the Bipolar II Disorder and to describe featu res of the m ost recent Major Depressive Ep isode (only if it is the mos t recent type of mood episode):
In Parti al Remission, In Full Rem ission (see p. 411) Chronic (see p. 41 7) With Catatonic Features (see p. 41 7) With Melancholic Features (see p. 419)
With A typical Features (see p. 420) With Postpartum Onse t (see p. 422) The follow ing specifiers may be used to indicate the pattern or frequ ency of epi sodes:
394
Longitudinal Course Specifiers (With and Without lntcrepisode Recovery) (see p. 424) Wi th Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) (see p. 425) Wi th Rapid Cycl ing (see p. 427)
296.89 Bipola r II Disorder (Recurrent Major Depressive Episodes With Hypomanic Ep isodes) addition, Rapid Cycling (see p . 427) is more common in women than in men. Some evidence sugges ts that mixed or depressive symptoms during H ypomanic Episodes may be m ore common in wom e n as well, altho ug h no t a ll studies are in agreement. Thus, women may beat particula r ris k fo r d epressive or inte rmixed mood symptoms. Women with Bipolar II Disorder may be at increased risk of developing subsequent episodes in the immedia te postpartum period.
Preva lence
Community s tudies s uggest a lifetime prevalence of Bipolar II Disorder of a pp roximately 0.5%.
Course
Roug hly 60%- 70% of the Hypomanic Episodes in Bipolar 11 Disorde r occur immediately before or after a Major Depressive Episode. H ypomanic Episodes often precede or fo llow the Major Depressive Episodes in a characteristic patte rn for a particular person. The number of lifetime e pisodes (bo th H yp omanic Episodes and Major Depressive Episodes) lend s to be h igher fo r Bipolar U Disorder compared with Major Depressive Disorder, Recurrent. The interval between episodes te nds to decrease as the individual ages. Approxim ately 5%- 15% of individuals with Bipolar 11 Disorder have mu ltiple (four or m o re) m ood episodes (Hypomanic o r Major Depressive) that occur within a g iven year. If this pattern is pres ent, it is no ted by the specifier With Rapid Cycling (see p. 427). A ra pi d-cycling pattern is associated w ith a poorer prognosis. Although the m ajority of individuals w ith Bipola r II Disorder return to a fully functio nal level between e pisodes, app roximate ly 15% co ntinue to display mood lability and interpersonal o r occupational difficulties. Psychotic symptoms do not occur in Hypomanic Episodes, and the}' appear to be less frequen t in the Major Depressive Episodes in Bipola r U Disorder than is the case for Bipolar I Disorder. Some evidence is consiste nt with the notion that marked changes in s leep-wake schedule such as occur during time zone changes or s leep depriva tion m ay precipita te or exacerbate H ypomanic o r Major Depressive Episodes. If a Manic or Mixed Episode d evelops in the course of Bipolar II Disorder, the diagnosis is changed to Bipolar I Disorder. Over 5 years, about 5%-15% o f individua ls with Bipolar II Disorder will develop a Manic Episod e.
Familial Pattern
Some studies have indica ted that first-degree biolOgiCal relatives of individuals with Bipolar 11 Dis order have e levated rates of Bipolar Il Disorder, Bipola r I Disorde r, and Major Depressive Disorder compared w ith the general p opulation.
Mood Disorders
The diagnosis is Mood Disorder Due to a General Medical Condition for episodes that are judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidis m) (see p. 401). This determination is based on the history, laboratory finding s, or physical examination. A Substance-Induced Mood Disorder is distinguished from Hyp omanic or Major Depressive Episodes that occur in Bipolar II Disorder by the fact that a substance (e.g., a drug of abu se, a medication, or exposure to a toxin) is judged to be etiologically related to the mood dis turbance (see p. 405). Symptoms like those seen in a Hypomanic Episode may be part of an intoxication with or w ithdrawal from a drug of abuse and should be diagnosed as a Substance-Induced Mood Disorder (e.g., a major depressive-like episode occurring only in the context of w ithdrawal from cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdraw al). Symptoms like those seen in a Hypomanic Episode may also be precipitated by antidepressant treatment such as medica tion, electrocon vulsive therapy, or light therapy. Such episodes may be diagnosed as a Substance-Induced Mood Disorder (e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features) and would n ot count toward a diagnosis of Bipolar n Disorder. However, when the substance use or medication is judged not to full y account for the episode (e.g., the episode continues fo r a considerable period autonomously after the substance is d iscontinued), the episode would coun t toward a diagnosis of Bipolar II Disorder. Bip olar II Disorder is distinguished from Major D epressive Disorder by the lifetime his tory of at least one Hypomanic Episode. Attention during the interview to whether there is a history of euphoric or d ysphoric hypomania is important in making a differential diagnosis. Bip olar II Disorder is distingu ished from Bipolar I Disorder by the p resence of one or more Manic or Mixed Episodes in the latter. When an individual p reviously diagnosed with Bipolar U Disorder develops a Manic or Mixed Episode, the diagnosiS is changed to Bipolar I disorder. In Cyclothymic Disorder, there are numerous periods of h ypomanic sym ptoms and nunlerous periods of depressive symptoms that do not meet symptom or duration criteria for a Major Depressive Episode. Bipolar II Disorder is distinguished from Cyclothymic Disorder by the presence of one or more Major Depressive Episodes. If a Major Depressive Episode occurs after the first 2 years of Cyclothymic Disorder, the additional diagnosis of Bipolar II Disorder is given. Bipolar II Disorder mus t be distinguished from Psychotic Disorders (e.g., Schizoaffective Disorder, Schizophrenia, and Delusional Disorder). Schizophrenia, Schizoaffective Disorder, and Delusiona l Disorder are all characterized by periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompan ying symptoms, previous course, and family history.
296.89 Bipola r II Diso rder (Recurrent Major Depressive Episodes W ith Hypoma nic Episodes)
397
D. The mood symptoms in Criteria A and B are not better accounted for by 5chizoaffec tive Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Diso rder Not Otherwise Specified. E. The symptoms cause clinically significant distress or impairment in social, occupation ai, or other important areas of functi o ning.
Specify current or most re cent episode:
Hypomanic: if currently (or most recently) in a Hypomanic Episode (see p. 368) Depressed : if currently (or most recently) in a Major Depressive Episode (see p. 356) If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status andlor featu res: Mild, Moderate, Severe With out Psychotic Features/Severe With Psychotic Features (see p. 41 1) Note : Fifthdigit codes specified on p. 413 cannot be used here because the code fo r Bipolar II Disorder already uses the fifth digit. Chron ic (see p. 417) With Ca tatonIc Features (see p. 41 7) With Melancholic Features (see p. 4 19) With Atypical Features (see p. 420) With Postpartum Onset (se e p. 422) If the full criteria are not currently met for a Hypoman ic or Major Depressive Episode, specify the cl inical status of the Bipolar 11 Disorder andlo r features of the most recent Majo r Depressive Episode (only if it is the most recent type of mood episode): In Pa rtial Remi ssion, In Full Re mission (see p. 4 11) Note: Fifthdi git codes specified o n p. 413 canno t be used here because the code for Bipolar II Disorder already uses the fifth digit. Chronic (see p. 417) With Catatonic Features (see p. 4 17) With Me lancholic Fea ture s (see p. 419) With Atypical Fe ature s (see p. 420) With Postpartum Onse t (see p. 422)
Specify:
long itudinal Course Specifiers (With a nd Without Intere pisode Recovery) (see p. 424) With Se asonal Patter n (a pplies only tothe pattern of Major Depressive Episodes) (se e p. 425) With Rapid Cycling (see p. 427)
398
Mood Disorders
301.13
Diagnostic Features
Cyclothymic Disorder
The essential feature of Cyclothymic Disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms (see p. 365) and numerOliS periods o f depressive symptoms (see p . 349) (Criterion A). The hypomanic symptoms are of ins ufficient number, severity, pervasiveness, or duration to meet full criteria for a Manic Episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a Major Depressive Episode. However, it is not necessary that any of the periods of hypomanic symptoms meet either the dura tion or symptom t1ueshold criterion for a Hypomanic Episode. During the 2-year period (1 year for children or adolescents), any symplomfree intervals last no longer than 2 months (Criterion B) . The diagnosis of Cyclothymic Disorder is made only if the initial 2-year period o f cyclothymic symptoms is free of Major Depressive, Manic, and Nfixed Episodes (Criterion C) . After the initial 2 years of the Cyclothymic Disorder, Manic or Mixed Episodes may be superimposed on the Cyclothymic Disorder, in which case both Cyclothymic Disorder and Bipolar J Disorder are diagnosed . Similarly, after the initial 2 years of Cyclothymic Disorder, Major Depressive Episodes may be superimposed on the Cyclothymic Disorder, in which case both Cyclothymic Disorder and Bipolar II Disorder are diagnosed . The diagnosis is not made if the pattern of m ood swings is better accounted for by Schizoaffective Disorder or is superimposed on a Psychotic Disorder, such as Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion D), in which case the mood symptoms are considered to be associated features of the Psych otic Disorder. The mood dis turbance must also not be due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medica1 condition (e.g., hyperthyroidism) (Criterion E). Although some people may function particularly well during some of the periods of hypomania, overall there must be clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged periods of cyclical, often unpredictable mood changes (e.g., the person may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable).
301 .13
Cyclothymic Disorder
in men and in women. In clinical settings, women with Cyclothymic Disorder may be
Prevalence
Studies have reported a lifetime prevalence of Cyclothymic Disorder of from 0.4% to 1%. Prevalence in mood disorders clinics may range from 3% to 5%.
Cou rse
Cyclothymic Disorder usually begins in adolescence or early adult life. Onset of Cyclothymic Disorder late in adult We may suggest a Mood Disorder Due to a General Medical Condition such as multiple sclerosis. Cyclothymic Disorder usually has an insidious onset and a chronic course. There is a 15%-50% risk that the person w ill subsequently develop Bipolar I or II Disorder.
400
Mood Disorders
fier With Rapid Cycling requires that full mood episodes be present. If a Major Dep ressive, Manic, or Nlixed Episode occurs during the course of an established Cyclothymic Disorder, the diagnosis of either Bipolar I Disorder (for a Manic or Mixed Episode) or Bipolar II Disorder (for a Major Depressive Episode) is given along with the diagnosis of Cyclothymic Disorder. Borderline Personality Disorder is associated with marked shifts in mood that may su ggest Cyclothymic Disorder. If the criteria are met for each disorder, both Borderline Personality Disorder and Cyclothymic Disorder may be diagnosed .
For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 368) and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In chi ldren and adolescents, the duration must be at least 1 year. not been without the symptoms in Criterion A for more than 2 months at a time.
B. During the above 2-year period ( 1 year in children and adolescents), the person has
C. No Maj or Depressive Episode (p. 356), Manic Episode (p. 362), or Mixed Episode (see p. 365) has been present during the first 2 years of the disturbance.
Note: After the initial 2 years (1 year in children and adolescents) o f Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed) . D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical cond ition (e.g., hyperthyroidism) .
F. The symptoms cause clinically sig nificant distress or impa irment in social, occupation aL or other important areas of functioning .
296.80
The Bipolar Disorder N ot Otherw ise Specified category includes disorders with bipolar features tha t do not meet criteria for any specific Bipolar Disorder. Examples include 1. Very rapid alternation (over days) beh veen manic symptoms and depressive symptoms that meet symptom tlueshold criteria but not minimal duration criteria for Manic, Hypomanic, or Major Depressive Episodes 2. Recurrent Hypomanic Episodes w ithout intercurrent d epressive symptoms 3. A Manic or Mixed Episod e superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Othen\'ise Specified
401
4. H ypomanic Episodes, along with chronic depressive symptoms, that are too infreque nt to qualify for a diagnosi5 of Cycloth ymic Disorder 5. Sihlations in which the clinician has concluded that a Bipolar Disord er is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced
1402
onset or course or absence of family history). Evidence from the literature that s uggests that the re can be a direct association between the genera l med ical condition in question and the d evelopment of mood symptoms can provid e a useful context in the assessment of a particular situation. In addition, the clinician mus t also judge that the disturbance is n ot bette r accounted for by a primary Mood Disorder, a SubstanceInduced Mood Disord er, or other primary mental d isorders (e.g., Adjustment Disorder). This determination is explained in greater detail in the "Mental Disorders Due to a General Medical Condition" section (p. 181). In contrast to Major Depressive Disorder, Mood Disorde r Due to a General Medical Condition, With Depressive Features, appears to be nearly equaUy distributed by gender. Mood Disorder Due to a General Medical Condition increases the risk of attempted and completed suicide. Rates of suicide are variable depending on the particular general medical condition, with chronic, incurable, and painful conditions (e.g., malignancy, spinal cord injury, peptic ulcer d isease, Huntington's disease, acquired immunodeficiency syndrome [A IDS], end-stage renal disease, head inju ry) carryin g the greatest risk for suicide.
Subtypes
One of the following subtypes may be used to indicate which of the foll owing symptom presentations predominates: With Depressive Features. This subtype is used if the predominant mood is depressed, but the full criteria for a Major Depressive Episode are not met. With Major Depressive-like Episode. This subtype is used if the full criteria (except Criterion D) for a Major Depressive Episode (see p. 356) are met. With Manic Features. This subtype is used if the predominant mood is elevated, euphoric, or irri table. With Mixed Features. This subtype is used if the symptoms of both mania and depression are presen t but neither predominates.
Recording Procedures
In recording the diagnOSis of Mood Disorder Due to a General Medical Condition, the clinicia n should note both the specific phenom enology of the d isturbance, including the appropriate subtype, and the identified general medical condition judged to be causing the d isturbance on Axis I (e.g., 293.83 Mood Disorder Due to Thyrotoxicosis, With Manic Features). The ICD-9-CM code for the general medical condition should also be noted on Axis TIl (e.g., 242.9 thyrotoxicosis) . (See Appendix G fo r a list of selected ICD-9.cM diagnostic codes for general medical conditions.) A separate diagnosis of Mood Disorder Due to a General Medica l Condition is not given if the d epressive symptoms d evelop exclusively during the course of Vascular Dementia . In this case, the d epressive symptoms are indicated by speci fying the subtype With Depressed Mood (i.e., 290.43 Vascular Dementia, With Depressed Mood).
293.83
Preva lence
Prevalence estimates for Mood Disorder Due to a General Medical Condition are confined to those presentations with depressive features. It has been observed that 25%40% of individuals with certain neurological conditions (including Parkinson 's disease, Huntington's disease, multiple sclerosis, stroke, and Alzheimer's disease) will develop a marked depressive d isturbance at some point during the course of the illness. For general medical conditions without direct central nervous system involvement, rates are far more variable, ranging from more than 60% in Cushing's syndrome to less than 8% in end-stage renal disease.
Differential Diagnosis
A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given if the mood disturbance occurs exclusively during the course of a delirium. In contrast, a diagnosis of Mood Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the mood symptoms are a direct etiological consequence of the pathological process causing the dementia and if the mood symptoms are a prominent part of the clinical presentation (e.g., Mood Disorder Due to Alzheimer's Disease). Because of ICD-9-CM coding requirements, an exception to this is when depressive symptoms occur exclusively during the course of Vascular Dementia. In this case, only a diagnosis of Vascular Dementia with the subtyp e With Depressed Mood is given; a separate diagnosis of Mood Disorder Due to a General Medical Condition is not made. If the presentation includes a mix of different types of symptoms (e.g., mood and anxiety), the specific mental disorder due to a general medical condition depends on w hich symptoms predominate in the clinical picture. If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a s ubstance, or exp osure to a toxin, a Substance-lnduced M ood Disorder should be considered . It may be useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation. Symptoms that occur during or shortly after (i .e., w ithin 4 weeks of) Substance Intoxication or Withdrawal or after medication use may be especially indicative of a SubstanceInduced Disorder, d epending on the character, duration, or amount of the substance used. If the clinician has ascertained that the disturbance isdue to both a general med -
404
Mood Disorde rs
ital condition and substance u se, both diagnoses (i.e., Mood Disorder Due to a General Medical Condition and Subs tance-Induced Mood Disorder) are given. Mood Disorder Due to a General Medical Condition must be distinguished from Major Depressive Disorder, Bipo lar I Disorder, Bipolar II Disorder, and Adj u stment Disorder With Depressed Mood (e.g., a maladaptive res ponse to the stress of having a general medical condition). In Major Depressive, Bipolar, and Adjus tment
D. Th e disturbance does not occu r excl usively during the course of a delirium. E. Th e symptoms came cli nica lly significant distress or impairment in social, occupational, or othe r important areas of functioning.
Specify type:
With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a Major Depressive Episode With Major Depress ive-like Episode: if the full criteria are met (except Criterion D) for a Major Depressive Episode (see p. 356) With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if the symptoms of both mania and depreSSion are present but neither predominates
Diagnostic criteria for 293.83 Mood Disorder Due to .. [Indicate the General Medica(Condition] (continued)
Coding note:
Include the name of the general med ica l condition on Axis I, e.g., 293.83 Mood Disorder Due to Hypothyroidism, With Depressive Features; also code the general medica l condition on Axis 111(see Appendix G for codes).
Coding note:
If depressive symptoms occur as part of a preexisting Vascular Dementia, indicate the depressive symptoms by coding the appropriate subtype, i.e., 290.43 Vascular Dementia, With Depressed Mood.
406
Mood Disorders
ample, the onset of a Manic Episode after age 45 years may suggest a substanceinduced etiology. In contras t, factors that suggest that the mood symptoms are better accoun ted for by a primary Mood Disorder include persistence of mood symptoms for a substantial period of time (Le., a month or more) after the end of Substance Intoxicati on or acute Substance Withdrawal; the development of mood symptoms that are substantially in excess of what would be expected given the type or amount of the substance used or the duration of u se; or a history of p rior recurrent primary episodes of Mood Disorder. Some medications (e.g., s timu lants, steroids, L-dopa, antidepressants) o r other somatic treatments for depression (e.g., electroconvulsive therapy or light therapy) can induce manic-like mood d is tu rbances. C linical judgment is essential to determine whether the treatmen t is truly causal or whether a primary Mood Disorder happened to have its onset while the person was receiving the treatment. For example, manic symptoms that develop in a person while he or s he is taking lithium would not be diagnosed as Substance-Induced Mood Disorder because lithium is not likely to induce manic-like episodes. On the other hand, a depressive episode that developed within the first several weeks of beginning alpha-methyldopa (an antihypertensive agent) in a person with no history of Mood Disorder would qualify for the diagnosis of AlphaMethyldopa-Induced Mood Disorder, With Depressive Features . In some cases, a previously established condition (e.g., Major Depressive Disorder, Recurrent) can recur while the person is coincidentally taking a medica tion that has the capacity to cau se depressive sym ptoms (e.g., L-dopa, birth-control p ills) . In such cases, the clinician must make a judgment as to whether the medication is causative in this particular situation. For a more detailed discussion of Substance-Related Disorders, see p. 191.
Subtypes a nd Specifiers
One of the following subtypes may be used to indicate which of the following symptom presentations predomina tes: Wi th Dep ressive Features. This subtype is used if the predominant mood is depressed. With Man ic Features. This subtype is used if the predominant mood is elevated, euphoric, or irritable. With M ixed Features. This subty pe is used if the symptoms of both mania and depression are present but neither predominates. The context of the development of the mood symptoms may be ind icated by using one of the following specifiers: Wi th O n set During Intoxication . This specifier should be used if cri teria for intoxication w ith the substance arc met and the symptoms develop during the intoxication syndrome. With O n set D u ring W ith drawal. This specifier should be used if criteria for withdrawal from the substance are met and the symptoms develop during, or shortly after, a withdrawal syndrome.
Recording Procedures
The name of the Substance-Induced Mood Disorder begins w ith the sp ecific s ubstance or somatic treatment (e.g., cocaine, amitriptyline, electroconvulsive therapy) that is presumed to be causing the mood symptoms. The diagnostic code is selected from the lis ting of classes of substances provided in the cri teria set. For subs tan ces that do not fit into any of the classes (e.g., amitriptyline) and for o ther somatic treatments (e.g ., electroconvu lsive therapy), the code for "Other Substance" should be used . In addition, for medications prescribed at therapeutic doses, the s pecific medica tion can be indica ted by listing the appropriate E-code (see Appendix G). The name of the disorder (e.g., Cocaine-Induced Mood Disorder) is followed by the subtype indicating the predominant symptom presentation and the specifier indicating the context in which the symptoms developed (e.g ., 292.84 Cocaine-Induced Mood Disord er, With Depressive Features, With Onset During Withdrawal). When more than one substance is judged to play a significant role in the development of mood symp toms, each should be lis ted separately (e.g., 292.84 Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Withdrawal; 292.84 Light Therapy-Induced Mood Disorder, With Manic Features). If a subs tan ce is judged to be the etiolog ical factor but the s pecific s ubstance or class of s ubstances is unknown, the category 292.84 Unknown Subs tan ce-Induced Mood Disorder may be used .
Specific Substances
Mood Disord ers can occur in association with intoxication with the follow ing classes of subs tances: alcoho l; amphetamin e and related s ubstances; cocaine; hallucinogens; inhalants; opioids; phencyclidine and related subs tances; sedatives, hypnotics, and anxiolytics; and other or unknown subs tances. Mood Disorders can occur in association w ith withdrawal from the foll owing classes of substances: alcohol; amphetamine and related substances; cocaine; sedatives, hypnotics, and anxiolytics; and other or unknown s ubs tances. Some of the medications reported to evoke mood symptoms include anes thetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, anti parkinsonian medications, antiulcer medications, cardiac medications, oral contraceptives, psychotropic medica tions (e.g., antidepressants, benzodiazepines, antipsychotics, disulfiram), muscle relaxants, s teroids, and s ulfonamides. Some medications have an especially high likelihood of producing depressive features (e.g ., high d oses of reserpine, corticosteroids, anabolic steroids). I ote that thi s is not an exhaus tive lis t of possible medications and that many medications may occasionally produce an idiosyn cratic depressive reaction. Heavy metals and toxins (e.g ., volatile subs tances su ch as gasoline and paint, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide) may also cause mood symptoms.
Differential Diagnosis
Mood symptoms occur commonly in Substance Intoxica tion and Substance Withdrawal, and the diagnosis of the substance-sp ecific intoxication or subs tance-specific withdrawal will us ually suffice to categorize the symptom presentation. A diagnosis
Mood Disorders
of Substance Induced Mood Disorder should be made instead of a diagnosis of Sub stance Intoxication or Substance Withdrawal only when the mood symptoms are judged to be in excess of those usually associated with the intoxication..or withdrawal syndrome and when the mood symptoms are sufficiently severe to warrant indepen d ent clinical a ttention. For example, d ysphoric mood is a characteristic feature of Cocaine Withdrawa l. Cocaine--Induced Mood Disorder should be diagnosed instead of Cocaine Withd rawal only if the mood disturbance is substantially more intense than what is usually encoun tered with Cocaine VVithdrawal and is sufficiently severe to be a separate focus of attention and treatment. If substanceinduced mood symptoms occur exclu sively during the course of a de lirium, the mood symptoms are considered to be an associated feature of the delirium and are n ot diag nosed separately. In su bstance induced presentations that contain a mix of different types of symp to ms (e.g., mood, psychotic, and anxiety symptoms), the specific type of Substancelnduced Disorder to be diagnosed depends on which type of sym p toms predominates in the clinical presentation. A Substance Induced Mood Disorder is distinguished from a primary Mood Dis order by the fact that a substance is judged to be etiologically related to the symptoms (p . 405). A Substance-Induced Mood Disorder due to a p rescribed treatment fo r a mental disorder or general medical condition must have its onset while the person is receiving the medication (e.g ., antihypertensive medication) or during withdrawa l, if there is a withdrawa l syndrome associated with the medication. Once the treatment is dis continued, the mood symptoms w ill usually remit within days to several wee~ (depending on the h alf-life of the substance and the presence of a withdrawal syr drome). U symptoms p ersist beyond 4 weeks, other cau ses for the mood symptom should be considered. Because individuals with genera l medical conditi ons often take med ica tions fc those conditions, the clinician must consider the possibility that the mood symptom are caused by the physiological consequences of the general medical condition ralhe; than the medication, in which case Mood Disord er Due to a General Medical Can dition is diagnosed. The history o ft en provides the primary basis for such a judg ment. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be need ed to determine empirically for that person w hether the m edication is the causa tive agent. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both d iagnoses (i.e., Mood Disorder Due to a General Medica l Condition and Substance-Induced Mood Disord er) may be given. When there is insufficient evidence to determine whether the mood symptoms are due to a substance (including a medica tion) or to a general medical condition or are p rimary (i .e., not due to either a substance or a general medical condition), Depressive Disorder No t Otherwise Specified or Bipolar Disorder Not Otherwise Specified would be ind icated.
409 1
(1) the symptoms in Criterion A developed during, or within a month of, Substance
Intoxication or Withdrawal (2) medicat ion use is etiologically related to the disturbance
C. The d isturbance is not bette r accounted for by a Mood Disorder that is not substance
induced. Evidence that the symptoms are better accounted for by a Mood Disorder that is not substance induced might include the follow ing : the symptoms precede the o nset ofthe substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or se vere intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-subst anceinduced Mood Disorder (e .g., a history of recurrent Major Depressive Episodes) . D. The disturbance does not occur exclusively during the course of a delirium.
E. The symptoms cause clinically significant distress or impai rment in social. occupation-
al, or other important areas of functioning . Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually asso ciated with the intoxication or wit hdrawal syndrome and when the symptoms are suffi ciently severe to warrant independent clinica l attention. Code [Specific Substance]-In duced Mood Disorder: (29 1.89 Alcohol; 292 .84 Amphetamine [or Amphetamine-Like Substance); 292.84 Cocaine; 292 .84 Hallucinogen; 292 .84 Inha lant; 292.84 Opioid; 292 .84 Phencycl idine lor Phencyclidine-li ke Substancej; 292.84 Sedative, Hypnotic, or Anxiolytic; 292.84 Other lor Unknown] Substance)
Specify type:
With Depressive Features: if the predom inant mood is depressed With Manic Features: if the predominant mood is e levated, euphoric, or irritable With Mixed Features : if symptoms of both ma nia and depression are present and neit her predominates
Specify if (see table on p.1 93 for applicabil ity by substance):
With Onset During Intoxication : if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawa l syndrome
Mood Disorders
A number of specifiers for Mood Disorders are p rovided to increase diagnostic specificity and create more h omogeneous subgroups, assist in treatment selection, and improve the prediction of prognosis. The Severity / Psychotic/ Remission specifie rs describe the current clin ica l status of the Mood Disorder. The following specifiers describe symptom or course features of the current m ood episode (or the most recent mood episode if criteria are not currently met for any episode): Chronic, With Catatonic Features, With Melancholic Features, With Atypical Features, and With Postpartum Onset. The specifiers that ind icate severity, remission, and psychotic features can be coded in the fifth digit of the diagnostic code for most of the Mood Disorders. The other specifiers cannot be cod ed. Table 1 indicates which episode specifiers apply 10 each Mood Disorder (see p. 411).
411
Tab le 1.
Chronic
X
Major Depressive Disorder, Si ngle Episod e Major Depress ive Disor der, Recurrent Dysthymic Disord er Bipol ar I Disorder, Sing le Manic Episode Bipol ar I Disorder, Most Rece nt Episode Hypomanic Bipol ar I Oisorder, Most Re cen t Episod e Manic Bipol ar I Disorder, M ost Recent Episo de M ixed Bipo lar I Disorder, M ost Recent Episo de Depressed Bipol ar I Disorde r, M os t Recent Episode Unspecified Bipol ar II Disorder, Hypoma nic Bipolar II Disorder, Depresse d Cyclothymic Disord er
X X X X
Mood Disorders Fea tures, or Severe With Psychotic Fea tures. If the criteria are no longer met, the specifier indicates w hether the most recent Major Depressive Epi sode is in partial or fu ll remission. For Major Depressive Disorder and most of the Bipolar I Disorders, the specifier is refl ected in the fifth-d igit cod ing for the d isorder. 1- Mild, 2- Moderate, 3-Severe Without Psychotic Features. Severi ty is judged to be mild, mod erate, or severe based on the number of criteria symptoms, the severity of the symp toms, and the degree of functional d isability and distress. Mild episodes are characterized by the presence of only fi ve or six depressive symptoms and either mild disability or the capacity 10 function normally but with substantial and unusual effort. Episodes that are Severe Withollt Psychotic Featllres are characterized by the presence o f most of the criteria symptoms and clear-cut, observable disability (e.g., inability to work or care for children). Moderate episodes have a severi ty that is intermedjale between mild and severe. 4--Severe With Psychotic Features. This specifier indicates the p resence of either delusions or hallucinations (typically auditory) during the curren t episode. Most commonly, the content of the d elusions or hallucinations is consisten t with the dep ressive themes. Such mood-congruen t psydwtic fratllres include d elusions of guilt (e.g., of being responSible for iUness in a loved one), d elusions of d eserved punishment (e.g., of being punished because of a mora l transgression or some personal inadequacy), nihi listic delusions (e.g., of world or personal d estruction), somatic delusions (e.g., of cancer or one's body "rotting away"), or d elusions o f poverty (e.g., of being bankrupt). Hallucinations, when present, are usually transient and not elabOmings or sins. orate and may involve voices that berate the person for shortC Less commonly, the content of the hallucinations or delusions has no appa rent relationship to d epressive themes. Such mood-illcongruent psychotic features include persecutory d elusions (without d epressive themes that the individual deserves to be persecuted ), d elusions of thought insertion (i.e., one's thoughts are not one's own), delusions of th ought broadcasting (Le., others can hear one's thoughts), and delusions of control (i.e., one's actions are under ou tsid e control). These features are associated with a poorer prognosis. The clinician can indicate the nature o f the psychotic fea tures by specifying With Mood-Congruent Fea tures or With Mood-Incongruent Fea tures. 5-ln Partial Rem ission, 6--In Full Remission. Full Remission requires a period of at least 2 mon ths in which there are no significant symptoms of d epression. There are h vo ways for the episode to be In Partia l Remission: 1) some symptoms of a Major Depressive Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a Major Depressive Episode, but the period of remission has been less than 2 months. If the Major Depressive Episod e has been superimposed on DysthymiC Disorder, the diagnosis o f Major Depressive Disorder, In Partial Remission, is not given once the full criteria for a Major Depressive Episode are no longer met; instead, the diagnosis is Dysthymic Disorder and Major Depressive Disord er, Prior History.
Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Major Depressive Episode
Note : Code in fifth digit. Mild, Moderate, Severe Without Psychotic Features, and Severe Wit h Psychotic Features can be applied only if t he criteria a re currently met for a Major Depressive Episode. In Partial Remission and In Fu ll Remission can be applied t o t he most recent Major Depressive Episode in Major Depressive Disorder and t o a Major Depressive Episode in Bipolar I or II Disorder only if it is the most rece nt type of mood episode . .x1-Mild: Few, if any, symptoms in excess of those requ ired to make t he diagnosis and symptoms result in only minor impairment in occupational fun ctioning or in usua l social activities or relationships with oth ers. . x2-Moderate : Sym ptoms or functional impa irment between "mi ld " and "severe." .x3-Seve re Without Psychotic Features : Several symptoms in excess of those reo quired to make t he diagnosis, and symptoms marked ly inte rfere with occupation al functioning or with usual social activities or relat ionships with othe rs . .)(4-Severe With Psychotic Features: Delusions or hallucinat ions. If possible, specify whether the psychotic features are moodcongruent or mood-incongruent: Mood-Congruent Psychotic Feature s: Delusions or hallucinat ions whose content is entirely consistent with the typica l depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Mood-Incongruent Psychotic Features: Delusions or hallucinat ions whose content does not involve typica l depressive themes of personal inadequacy, guilt, disease, death, nihil ism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought inse rti on, thought broadcasting, a nd delusions of control. .)(5- 1n Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once t he fu ll criteria for a Major Depressive Episode are no longer met .) .)(6-ln Full Remission: During the past 2 mont hs, no significant signs or symptoms of the disturbance were present .
,x~nspeclfied .
414
Mood Disorders
l-Mild, 2-Moderate, 3-Severe Without Psych otic Features. Severity is judged to be mild, moderate, or severe based on the number of criteria symptoms, the severity o f the symptoms, the degree of fu nctional disabili ty, and the need for supervision. Mild episodes are characterized by the p resence of only three or four manic symptoms. Modera te episodes are ch aracterized by an extreme increase in activity or impairment in judgment. Episodes that are Severe Witliollt Psychotic Featllres are characterized b}' the need fo r al most continual superv ision to protect the individual from harm to sell or others.
4-Severe With Psychotic Features. This specifi er ind ica tes the presence of either
415
Criteria for Severity/Psychotic/Remission Specifiers for current (or most recent) Manic Episode
Note: Code in fifth digit. Mild, Moderate, Severe Without Psychotic Feat ures, and Severe Wit h Psychotic Features can be applied o nly if the criteria are currently met for a Manic Episode. In Partial Remission and In Full Remission can be appl ied to a Manic Episode in Bipola r I Disorder on ly if it is the most recent type of mood episode . .xl-Mild: Minimum symptom criteria a re met for a Manic Episode . .x2-Moderate: Extreme increase in activity or impairment in judgment. .x3-Severe Without Psychotic Features: Almost continua l supervision required to prevent physica l harm to self or others . .x4-Severe With Psychotic Features: De lusio ns o r ha llucinations. If possible, specify whether t he psychotic features are mood-congruent or mood-incongruent: Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth. power, knowledge, identity, or special relationsh ip to a deity o r famous person. Mood-Incongruent Psychotic Features: Delusions or hallucinations whose conte nt does not involve typical manic themes of inflated worth, power, knowledge, identity, or speCial relationship to a deity o r famous person . Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), t hought insertion, and delusions of being controlled . .xS-ln Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period w ithout any sign ificant symptoms of a Manic Episode lasting less than 2 months foll owing the end of the Manic Episode . .x6-ln Full Remission: During the past 2 months no signifi cant signs or symptoms of the disturbance were present . .xO-Unspecified.
416
toms and fi ve or s ix depressive symptoms. Moderate episodes are characterized by an extreme increase in activity or impaimlent in judgmen t. Episodes that are Severe Without Psyclwtic Features are characterized by the need for almost continual supervision to protect the individual from ham l to self or others.
4-S evere W ith Psychotic Features. This specifier indica tes the presence of either delusions or hallucinations (typically auditory) during the current episode. Most commonly, the content of the delusions or hallucinations is consistent with either the manic or depressive themes, that is, they are mood-coJlgruell t psycl10ticfen tures. For example, God's voice may be heard explaining that the person has a specia l mission. Persecutory delusions may be based on the idea that the person is being persecuted because of being especial ly deserving of punishment or having some special relationship or attribute. Less conunonly, the content of the hallucinations or delusions has no apparent relationship to either manic or depressive themes, that is, they are mood-iI/congruent psyd lOfic fea f flres. These may include delusions of thought insertion (i.e., one's thoughts are not one' s own), delusions of thought broadcasting (i.e., others can hear one' s thoughts), and delus ions of control (i.e., one's actions are un der ou tside control). These features are associated with a poorer prognosis. TIle clinician can indicate the nature of the psychotic features by specifying With Mood-Congruent Features or With Mood-Incongruent Features.
5-Jn Pa rtial Remission, &-I n Full Remi ss io n. Full Remission requires a period of at least 2 months in which there are no significant symptoms of mania or depression. There are two ways for the episode to be In Partial Remission: 1) symptoms of a Mixed Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a ~1ixed Episode, but the p eriod of remission has been less than 2 months.
Cri t eria for Severity/PsychotidRemission Specifiers for current (or most recent) Mixed Episode
Note: Code in fifth digit. Mi ld, Moderate, Severe Without Psychotic Featu res, and Severe With Psychotic Features can be applied only if the criteria a re current ly met fo r a Mixed Episode. In Partial Remission and In Full Remission can be applied to a Mixed Episode in Bipolar I Disorder only if it is the most recent type of mood episode . .x1-Mild: No more t han min imum symptom criteria are met for bot h a Man ic Episode and a Major Depressive Episode . .x2-Moderate: Symptoms or functio nal impairme nt betwee n " mild" and "severe. ~ ,x3-Severe Without Psychotic Features: Almost continual supervision requi red to prevent physical ha rm to self or others. ,x4-Severe With Psychotic Features: Delusions or hallucinat ions. If possibl e, specify whether the psychotic features are mood-congrue nt or mood-incong ruent:
417
Criteria for SeveritylPsychoticlRemission Specifiers for current (or most recent) Mixed Episode (continued)
MoodCongruent Psychotic Features: Delusions or hallucinations whose conte nt is e ntirely consiste nt with the typical manic o r depressive themes. Moodlncongruent Psychotic Features: Delusions or halluci nations w hose content does not involve typica l manic o r depressive themes. Included are such symptoms as persecutory delusions (not directly related to g randiose o r depressive themes), t hought insertion, and delusions of bei ng controlled . .x5-ln Partial Remission: Symptoms o f a Mixed Episode a re present but fu ll criteria are not met, o r there is a period without any significa nt symptoms o f a Mixed Episode lasting less than 2 months fo llowing the end of the Mixed Episode . .x6-ln Full Remission: During t he past 2 months, no significant signs or symptoms o f the d isturbance were p rese nt . .xO-Unspecified.
Chronic (can be applied to the current o r most recent Majo r Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipola r I o r II Disorder o nly if it is the most recent type o f mood episode) Full criteria fo r a Major Depressive Episode have been met continuously for at least the past 2 years.
Mood Disorders may involve m o loric immobility, excessive m o lar activity, extre me negativis m , mutism , peculiarities of voluntary m oveme nt, echolalia, or echopraxia. M o io ric immobility may be manifested by ca ta lepsy (waxy flexibility) or stupor. The excessive motor activity is ap parently purposeless and is no t influenced b y external stimuli. There may be extreme negativism thai is manifested by the maintenance of a rigid posture against aHempts to be moved. o r res is tance to all ins tructions. Pecu lia rities of voluntary movement are m a nifested b y the assumption of inappropriate or bizarre postures or by promine nl grimacing. Echo lalia (the pathological, parrotlike, and apparently senseless repetiti on o f a word o r phrase jus t spoken by another person ) and echop raxia (the repetitive imitation of the movements o f another person) are often p resent. Additional features may include s te reoty pies, manne rism s, and automatic obedience or mimicry. During severe catato nic stup or or excitem e n t, the person may need careful supervis io n 10 avoid self-harm or ha rm to others. Po te ntial conseque nces include malnutrition, exhaustio n, hyperpyrexia, o r self-inflicted injury. Ca tatonic states have been found to occur in 50/0 -9% of inpatients . Among inpatients w ith catalonia, 250/0 -50% of cases occur in a ssociation with Mood Disorders, 10/ -15% of cases occur in associatio n with Schizophrenia (see Schizophre nia, Cata0 tonic T ype, p. 31 5), and the remainder occur in association with other menial disord ers (e.g., Obsessive-Compuls ive Diso rder, Personality Disorders, and Dissociative Disorders). It is important to no te that catatonia can also occu r in a w ide va riety of general medica l conditions including, bu t not limiled 10, those due to infectious, metabolic, neurological conditions (see Catato ni c Disorder Due to a Gen era l Medi ca1 Condi tion, p . 185), or can be due to a side e ffect of a m edication (e.g., a MedicationIndu ced Movemen t D iso rde r, see p. 791). Because o f the seriousness of the complications, particular attention should be paid to the p ossibility that the catatonia is due to Neurolep tic Malign ant Syn drome (p . 795).
With Catatonic Features (can be appl ied to the current o r mort recent Major Depressive Episode, Manic Episode, o r Mixed Episode in Ma jor Depressive Disorder, Bipolar I Disorder, or Bipola r II Disorder)
The cl inica l picture is dominated by at leart two o f the following:
(1 ) matoric immobility as evidenced by catalepsy (i ncluding
W3)(IJ
flexibility) or
stupor
(2) excessive motor activity (t hat is a pparently purposeless and not influenced by external stimuli) (3) extre me negat ivism (an appa rent ly motiveless resista nce to all instructions or maintenance of a rigid posture aga inst attempts to be moved) or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate o r bizarre postures), stereotyped movements,
prom inent mannerism s, or prominent grimacing
420
With Melancholic Features (can be applied to the current o r most recent Major
Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Oisorder only if it is the most recent type of mood
episode)
A. Either of the following, occurring during the most severe period of the current
episode:
(1) loss of pleasure in all, or almost all, activities
(2) lack of reactivity to usually pleasurable stimuli (does not fee l much better, even temporarily, when something good happens)
B. Th ree (or more) of the following:
(1) distinct quality of depressed mood (i.e., the depressed mood is experienced
(2) (3)
as distinctly different f rom the kind of fe eling experienced after the death of a loved one) depression regularly worse in the morning earl y morning awakening (at least 2 hours before usual time of awakening) marked psychomotor reta rdat ion or agitation significant anorexia or weight loss excessive or inappropriate guilt
421
Mood reactivity is the capacity to be cheered up when presented with positive ~\'ents (e.g., a visit from children, compliments from others). Mood may become euthymic (no t sad) even for extended periods o f time if the external circumstances remain fav orable. Increased appetite may be manifested by an obviolls increase in food intake or by weigh t gain. Hypersomnia may include either an extended period of nighttime sleep or d aytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Lead en paralysis is defined as feeling heavy, leaden, or weighted d own, uSlially in the arms or legs; this is generally present for at least an hour a day but often lasts for many hours at a time. Unlike the other atypical fea tures, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult We. Rejection sensitivity occurs both when the person is and is not d epressed, though it may be exacerbated during d epressive periods. The problems that result from rejection sensitivity must be significan t enough to result in fun ctional impairmen t. There may be stormy relationships with frequ ent disruptions and an inability to sustain a longer-lasting relationship. The individual's reaction to rebuff or criticism may be manifested by leaving work early, using substances excessively, or d isplaying o ther clinically significant malada p tive behavioral responses. TIlere may also be avoi dance of relationships due to the fea r of interpersonal rejection. Being occasionally touchy or overemotional does not qualify as a manifestation of interpersonal rejection sensitivity. Personality Disorders (e.g., Avoidant Personality Disorder) and Anxiety Disorders (e.g., Separation Anxiety Disorder, SpeCific Phobia, or Socia l Phobia) may be more common in those with atypical features. The laboratory find ings associated with a Major Depressive Episode With Melancholic Features are generaUy not present in associa tion w ith an episode with atypica l features. Aty pical features are two to three times more common in women. Individuals w ith atypical features report an earlier age at onset of their depressive episodes (e.g., while in high school) and frequently have a m ore ciuonic, less episodiC course, with only partial in terepisode recovery. Younger individuals may be more likely to have episodes with atypical fea tures, whereas older individuals may more often have episodes w ith melancholic features. Episodes with atypical features are more common in Bipolar I Disorder, Bipolar II Disorder, and in Major Depressive Disorder, Recurrent, occurring in a seasonal pattern. Depressive episod es with Atypical Features are more likely to respond to treatment with monoam ine oxidase inhibitors than with tricyclic antidepressants. The predictive value of Atypical Fea tures is less clear with newer treabnents, such as selective serotonin reuptake inhibitors or interpersonal or cogniti ve psychotherapies.
422
Mood Disorders
With Atypical Features (can be applied when these features predominate during the most recent 2 weeks of a current Ma jor Depressive Episode in Major Depressive
Disorder or in Bipolar I or Bipolar II Disorder when a cu rrent Major Depressive
Episode is the most recent type of mood episode, or when these features predominate d uring the most recent 2 years of Dyrthymic Disorder; if the Major Depressive Episode is not current, it applies if the feature predomi nates during any 2-week
period)
A. Mood reactivity (i.e., mood brightens in response to actual or potentia l positive events)
B. Two (or more) of the following featu res:
C. Criteria are not met for With Melancholic Features or With Catatonic Features
during the same episode.
partum episodes with psychotic fea tures is particu larly increased for women w ith prior p ostpartum mood ep isodes but is also elevated for those with a prior history of a Mood Disorder (especially Bipolar I Disorder). Once a woman has had a postpartum. episode w ith psychotic features, the risk of recurrence with each subsequent delivery is beh "een 30% and 50%. There is also some evidence of increased ris k of postpartum psychotic mood episodes among women without a his tory of Mood Disorders with a famil y h istory o f Bipolar Disorders. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is d istinguished by a decreased level of awareness or attention. Women with postpartum Major Depressive Episodes often have severe anxiety and even Panic Attacks. Maternal attitudes toward the infant are highly variable but can include dis interest, fea rfulness of being alone w ith the i.nfant, or overintrusiveness that inhibits adequate infant res t. It is important to dis tinguish pos tpartum mood episodes from the "baby blues," which affect up to 70% of women during the 10 days postpartum, are transient, and do not impair functioning . Prospective studies have d emonstrated that mood and anxiety symptoms during pregnancy, as well as the "baby blues," increase the ris k for a postpartum Major Depressive Episod e. A past personal history of nonpostpartum Mood Disorder and a famil y history of Mood Disorders also increas e the risk for the development of a postpartum Mood Disorder. The risk factors, recurrence rates, and symptoms of postpartum-onset Mood Episodes are simila r to those of n onpostparlum Mood Episodes. However, the postpartum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adju stments, the poten tial impact of breast-feeding on treatment p lanning, and the long-term implications of a his tory of p ostpartum Mood Disorder on subsequent famil y planning.
With Postpartum Onset (can be applied to the current or most recent Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder; or to Brief Psychotic Disorder)
424
Table 2. Course spe cifiers th at appl y t o Mood Disord ers
WithIWithout Inte repisode Re covery
Majo r Depressive
Disord er, Single
Seasonal Pattern
Ra pid Cycling
Ep isod e
M ajor Depressive
Episo de
Bipolar I Disord er,
Most Recent
Episo de Manic
Bipola r I Disorder,
Most Recent
Episode M ixed Bipolar I Disorder, M on Recent
Episode De pressed
Bipolar I Disorder, M on Recent Episode Unspeci f ied Bipolar II Disorde r, Hypomanic Bipolar II Disorde r,
X X
X X
X X
Depressed
Cydo thymic Disorder
Seasonal Pattern Specifi er symptoms persist between the two most recent episodes-that is, no more than partial remission is attained. C shows the rare pattern (present in fewer than 3% of individuals with Major Depressive Disorder) of Major Depressive Disorder, Recurrent, w ith antecedent Dysthymic Disorder but with full interepisode recovery between the two most recent episod es. D shows the course of Major Depressive Disorder, Recurrent, in which there is antecedent Dysthymic Disorder and in which there is no period of full remission behveen the two most recent episodes. llus pattern, commonly referred to as "double dep ression" (see p. 377), is seen in about 200/0-25% of individuals with Major Depressive Disorder. In general, individuals with a history of Without Full interepisode Recovery have a persistence of that pattern beh\'een subsequent episodes . They also appear more likely to have more Major Depressive Episodes than those wi th full in terepisode recovery. Dysthymic Disorder prior to the fi rst episode of Major Depressive Disorder is most likely to be associated w ith lack of full interepisode recovery subsequently. These specifiers may also be applied to the period of time behveen the most recent mood episodes in Bipolar I Disorder or Bipolar II Disorder to indicate presence or absence of mood symptoms.
A. Recurrent, with full interepisode recove ry, with no Dysthymic Disorder B. Recurrent, without full interepi~ode recovery. with no Dysthymic d isorder C. Recurrent, w ith full interepisode recovery. superimposed o n Dynhymic Disorder (a lso code 300.4) D. Recurrent. without full interepisode recovery. super imposed on Dysthymic Disorde r (also code 300.4)
Bipolar I or II Disorder): With Fullinterepisode Recovery: if full remission is attained between the nvo most recent Mood Episodes Without Fulllnterepisode Recovery: if full remission is not atta ined between t he two most recent Mood Episodes
426
Mood
O isorder~
at characteristic times of the year. Ln most cases, the episodes begin in fa ll or winter and remit in spring. Less commonly, there may be recurrent summer depressi,'e
episodes. nus pattern of onset and remission of episodes mus t have occurred during the last 2 years, withou t any nonseasonal episodes occurring during this p eriod. In addition, the seasonal depressive episodes mus t subs ta ntially outnumber any nonseasonal depressive episodes over the individual's lifetime. This specifier does not app ly to those situati ons in which the pattern is better explained by seasonally linked psychosocial siressors (e.g., seasonal unemployment o r school schedule). Major J)e.. p ressive Episodes that occur in a seasonal paUern are often characterized by prominent anergy, hy persomnia, overeating, weigh t gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in Major Depressive Disorder, Recurren t, or in Bipolar Disorders. However, within the Bipolar Disorders group, a seasonal pattern appea rs to be mo re likely in Bipolar n Diso rd er than in Bipolar I Disorder. In some individuals, the onset o f Manic or Hypomanic Episodes may also be linked to a pa rticular season. Bright visible-spectrum tight used in trea tment may be associated w ith switches into Manic or Hypomanic Episodes. The prevalence o f w inter-type seasonal pattern appears to vary with latitude, age, and sex. Pre\'alence increases with higher la titudes. Age is also a s trong predictor of seasonality. w ith younger persons at higher risk for winter d epressive episodes. Women comprise 60%--90% of persons with seasonal pattern, but it is unclear whether female gender is a sp ecific risk facto r over and above the risk associated with recurrent Major Depressive Disorder. AJthough this specifier applies to seasonal occurrence of fu ll Major Depressive Episodes, some research suggests that a seasonal pattern may also describe the presentation in some individuals w ith recurrent winter d epressive episodes that do not meet criteria for a Major Depressive Episode.
Rapid-Cycling Specifier
427
Note : 0 0 not include cases in which there is an obvious eHect of seasonalrelated psychosocial stressors (e.g., regularly being unemployed every winter). B. Full rem issions (or a ch ange from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal re lationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period. D. Seasonal Major Depressive Episod es (as described above) substantially out number t he nonseasonal Major Depressive Episodes that may have occurred over the ind ividual's lifetime.
Rapid-Cycling Specifier
The specifier With Rapid Cycling can be applied to Bipolar I Disorder or Bipolar II Disorder. The essential feature of a rapid-cyding Bipolar Disorder is the occurrence of four o r more mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and symptom criteria for a Major Depressive, Manic, Mixed, or Hyp omanic Episode and must be demarcated by either a period of full remission or by a sw itch to an ep isode of the opposite polarity_ Manic, Hypomanic, and Mixed Episodes are counted as being on the sam e pole (e.g., a Manic Episode immediately followed by a rvli;xed Episode counts as only one episode in considering the specifier With Rapid Cycling). Except for the fact that they occur more frequently, the episodes that occur in a rapidcycling pattern are no different from those that occur in a non rapid -cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g., cocaine, corticosteroids) or a general medica l condi tion. Rapid cycling occu rs in approximatel)' 10%-20% of individuals w ith Bipolar Dis order seen in Mood Disorders clinics. \<\'hereas in Bipo lar Disorder in general the sex ratio is equal, women comprise 70%- 90% of individuals wi th a rapid-cycling pattern. The mood episodes a re not linked to any p hase of the menstrual cycle and occur in both pre- and postmenopausal women. Rapid cycling may be associated with hypo--
Mood Disorders
thyroid ism, certain n eurologica l conditions (e.g., multiple sclerosis), Mental Retardation, head injury, or antidepressant treatment. Ra pid cycling can occur at any time during the course of Bipolar Disorder and may appear and d isappear, particularly if it is associated with antidepressant use. There is some evidence that some indi viduals with rapid cycling have an acceleration of their cycling rate after exposure to antidepressant medication. The development of rapid cycling is associated w ith a poorer longer-term p rognosis.
With Rapid Cycl ing (can be ap plied to Bipolar I Disord er o r Bipolar II Disorder) At least four episodes of a mood d istu rbance in t he previous 12 months that meet criteria for a Major Depressive, Man ic, Mixed, or Hypoma nic Ep isode. Note: Episodes are demarcated either by partial o r full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., Major Depressive Ep isode to Manic Episode).
Anxiety Disorders
Agoraphobia, Panic Disorder With Agoraphobia, Agoraphobia Without History of Panic Disorder, Specific Phobia, Social Phobia, Obsessive-Compu!sive Disorder, Posttraumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, Anxiety Disorder Due to a General Medical Condition, Substancelnduced Anxiety Disorder, and Anxiety Disorder Not Otherwise Specified. Because Panic Attacks and Agoraphobia occur in the context of severa l of these disorders, criteria sels for a Panic Attack and fo r Agoraphobia are listed separately at the beginning of tlus section. A Panic Attack is a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associa ted with fee lings o f impending doom. During these attacks, symptoms such as sh ortness of breath, palpitations, chest pain or discomfort, choking o r smothering sensa tions, and fear of "going crazy" or losing control are present. Agoraphobia is anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of hav ing a Panic Attack or panic-l ike symptoms. Panic Disorder Without Agoraphobia is characterized by recurrent tmexpected Panic Attacks abou t which there is persistentconcem. Panic Disorder With Agoraph obia is characterized by both recurrent unexpected Panic Attacks and Agoraphobia. Agoraphobia Without Histo ry of Panic Disorder is characterized by the presence of Agoraphobia and panic-like symptoms without a history of unexpected Panic Attacks. Sp ecific Phob ia is characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior. Social Phobia is characterized by cl in ically significant anxiety provoked by exposure to certain types of social or performance situa tions, often leading to avoidance behavior. Obsessive-Compuls ive Diso rder is characterized by obsessions (which cause ma rked anxiety or distress) and / or by compulsions (wh ich serve to neutralize anxiety). Posttraumati c Stress Disorder is characterized by the reexperiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated w ith the trauma . Acute Stress Disorder is characterized by symptoms similar to those of Posttraumatic Stress Disorder that occur immed iately in the aftermath of an extremely traumatic event. Generalized Anxiety Disorder is characterized by at least 6 months of persisten t and excessive anxiety and worry.
429
430
Anxiety Disorder Due 10 a General Medical Condition is characterized by prominent symptoms of anxiety that are judged to be a d irect ph ysiological consequence of a general medical cond ition. Subs tance-Induced Anxiety Disorder is characterized by prominent symptoms of anxiety that are judged to be a direct physiological consequence o f a drug of abuse,
Panic Attack
Features
Because Panic Attacks can occu r in the context of an y Anxiety Disorder as well as other mental disorders (e.g., Mood Disorders, Substance-Related Disorders) and some genera l medical conditions (e.g., cardiac, respira tory, vestibular, gastrointestinal), the text and criteria set for a Panic Attack are p rovided separately in this section. The essentiaJ featu re o f a Panic Attack is a discrete period o f intense fear ordiscomfort in the absence of real danger that is accompanied by at ieast 4 of 13 somatic or cognitive symptoms. Symptoms can be somatic or cognitive in nature and include palpitations, swea ting, trembling or shaking, sensa tions of shortness of breath or smothering, feeling of choking, ch est pain or discomfort, nausea or abdominal distress, d izziness or ligh theadedness, derealization or depersonalization, fear of losing control or "going cra zy," fear o f d ying, paresthesias, and chills or hot flu shes. The .1 ttack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is oft en accompanied by a sense of imm inent d anger or impending doom and an u rge to escape. The anxiety that is characteristic of a Panic Attack can he differentiated from generalized anxiety by its discrete, almost pa roxysmal, nature and its typicall)' greater severity. Attacks that meet all other criteria but that have fewer than-1 somatic or cognitive symptoms are referred to as limited -symptom attacks. There are three ch aracteristic types of Panic Attacks: unexpected (uncued), situationally bound (cued), and situation ally predisposed. Each typ e o f Panic Attack is defined by a different set of relationships between the onset o f the attack and the presence or absence of situational triggers that can include cues that are either external (e.g., an individual with claustrophobia has a.n attack while in a elevator stuck beh veen fl oors) or internal (e.g., catastroph.ic cognitions about the ramifications of heart palpita tions). Unexpected (uncued) Panic Attacks are defined as those for which the individual does not associate onset with an internal o r external situational triggpr
Panic Attack
(i.e., the attack is perceived as occurring spontaneously "out of the blue"). Situationally bound (cued) Panic Attacks are defined as those that almost invariably occur immedia tely on exposure to, or in anticipation of, the situational cue or trigger (e.g., a person w ith Social Phobia having a Panic Attack upon entering into or thinking about a public speaking engagement). Situ ation ally predisposed Panic Attacks are similar to situationally bound Panic Attacks but are not invariably associated with the cue and do not necessarily occur immediately aft er the exposure (e.g., attacks arc more likely to occur while driving, but there are times when the individual drives and d oes not have a Panic Attack or times when the Panic Attack occurs after d riving for a half hour). Individua ls seeking care for unexpected Panic Attacks will usua lly describe the fear as intense and report that they though t they were about to die, lose control, have a heart attack or stroke, or "go crazy." They also usually repo rt an urgent desire to flee from w herever the attack is occurring. With recurrent unexpected Panic Attacks, over time the attacks typically become situationally bound o r predisposed, although unexpected attacks may persist. The occurrence of unexpected Panic Attacks is required for a d iagnosis of Panic Disorder (with or without Agoraphobia). Situationally bound and situationally predisposed attacks are frequent in Panic Disorder but also occur in the context of other Anxiety Disorders and other mental disorders. For example, situationally bound Panic Attacks are experienced by a majority of individual s with Social Phobia (e.g., the person experiences a Panic Attack each and every time she m ust speak in public) and Specific Phobias (e.g., the person with a Specific Phobia of dogs experiences a Panic Attack each and every time he encounters a barking dog), whereas s ituationa~ y predisposed Panic Attacks most ty pically occur in Generalized Anxiety Disorder (e.g., after wa tching television news programs that warn of an economic slowdown, the", person becomes overwhelmed with worries about his finances and escalates into a Panic Attack) and Posttraumatic Stress Disorder (e.g., a rape victim sometimes experiences Panic Attacks when faced with reminders of the traumatic event, such as seeing a man who reminds her of the assailant). In determining the differential d iagnostic significance of a Panic Attack, it is important to consider the context in which the Panic Attack occurs. The distinction between unexpected Panic Attacks and both situationally bound and situationally predisposed Panic Attacks is critical, since recurrent unexpected attacks are required for a diagnosis of Panic Disorder (see p. 433). Determining whether a history of Panic Attacks warrants a diagnOSiS of Panic Disorder is, however, complicated by the fact that an exclusive relationship does not always exist between the type of Panic Attack and the diagnosis. For instance, although a diagnOSiS of Panic Disorder d efinitionally requires that at least some of the Panic Attacks be u nexpected, individ uals with Panic Disorder frequently report also having situationally bound o r situationally predisposed attacks. As such, carefu l consideration of the focus of a.pxiety associated with the Panic Attacks is al.so important in differential diagnosis. To illustrate, consid er a woman w ho has a Panic Attack prior to a public speaking engagement. If this woman indicates that the focus of her anxiety was that she might die from an impending heart attack, then assuming other djagnostic criteria are met, she may have Panic Disorder. If on the other hand, this woman identifies the focu s of anxiety as not the Panic Attack itself, but of being embarrassed and humiliated, then she may be more likely to have
Anxiety Disorders
Social Phobia. The d iagnostic issues fo r boundary cases are d iscussed in the "Differential Diagnosis" sections of the texts for the disorders in which Panic Attacks may appear.
palpitations, pounding heart. or accelerated heart rate sweating trembling or shaking sensati ons of shortness of breath or smothe ring feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derea li zation (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations) chi lls or hot f lushes
Agoraphobia
Features
Because Agoraphobia occurs in the context of Panic Disorder With Agoraphobia and Agoraphobia Without History of Panic Disorder, the text and criteria set for Agoraphobia are provided separately in this section. The essential feature of Agoraphobia is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a Panic Attack (see p. 430) or panic-like symptoms (e.g., fcar of having a sudden attack of dizziness or a sudden attack of diarrhea) (Criterion A). The anxiety typically leads to a pervasive avoidance of a variety of situations that may include being alone outside the home or being home alone; being in a crowd of people; traveling in an automobile, bus, or airplane; or being on a bridge or in an ele\'ator. Some individuals are able to expose themselves to the feared situations but endure these experiences with considerable dread . Often an individual is better able to confront a feared situa tion when accompanied by a companion (Criterion B). Individuals' avoidance of situations may impair their ability to travel to work or to carry out homemaking responsibilities (e.g., grocery shopping, taking children to the doctor). The anxiety or phobic avoidance is
Panic Disorder
433
,lot better accounted for by another mental disorder (Criterion C). The differential di-
agnosis to distinguish Agoraphobia from Social and Specific Phobia and from severe Separation Anxiety Disorder can be difficult because all of these conditions are characterized by avoidance of specific situations. The diagnostic issues for boundary cases are discussed in the "Differential Diagnosis" sections of the texts for the disorders in which avoidant behavior is an essential or associated feature.
Note: Consider the diagnosis of Specific Phobia if t he avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations. B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiet y about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), ObseSSive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives) .
Pa n ic Di sorder
Diagnosti c Featu res
The essential feature of Panic Disorder is the presence of recurrent, unexpec:ted Panic Attacks (see p. 430) followed by at least 1 month of persistent concern about having another Panic Attack, worry about the pOSSible implications or consequences of the Panic Attacks, or a Significant behavioral change rela ted to the attacks (Criterion A). The Panic Attacks are not due to the direct physiological effects of a substance (e.g., Caffeine Intoxication) or a general medical condition (e.g., h yperthyroidism) (Criterion C). Finally, the Panic Attacks are not better accounted for by another mental dis-
Anxiety Disorders order (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder) (Criterion D). Depending on whether criteria are also met for Agoraphobia (see p. 433), 300.21 Panic Disorder With Agoraphobia or 300.01 Panic Disorder Without Agoraphobia is diagnosed (Criterion B). An unexpected (spontaneous, uncued) Panic Attack is defined as one that an individual does not inunediately associate with a situational trigger (i.e., it is perceived as occurring "out of the blue"). Situational triggers can include stimuli that are either external (e.g., a phobic object or situation) or internal (e.g., physiological arousal) to the individual. In some instances, although a situational trigger may be apparent to thedinician, it may not be readily identifiable to the individual experiencing the Panic Attack. For example, an individuaJ may not immediately identify increased autonomic arousal induced by a hot, stuffy room, or feelings of faintness produced by quickly sitting up as triggers for a Panic Attack, and as such, these attacks are considered at the time to be unexpected. At least two unexpected Panic Attacks are required for the diagnosis, but most individuals have considerably more. Individuals with Panic Disorder frequently also have situationally predisposed Panic Attacks (i.e., those more likely to occur on, but not invariably associated w ith, exposure to a situational trigger). Situationally bound attacks (i.e., those that occur almost invariably and immediately on exposure to a situational trigger) can occur but are less common. The frequ ency and severity of the Panic Attacks vary widely. For example, some individuals have moderately frequen t attacks (e.g., once a week) that occur regularly for m onths at a time. Others report short bursts of more frequent attacks (e.g., daily for a week) separated by weeks or months without any attacks or with less frequent attacks (e.g., two each month) over many years. Limited-symptom attacks (i.e., attacks that are identicaJ to "full" Panic Attacks except that the sudden fear or anxiety is accompanied by fewer than 4 of the 13 symptoms) are very common in individuals w ith Panic Disorder. Although the distinction between full Panic Attacks and limited-symptom attacks is somewhat arbitrary, full Panic AHacks are typicaUy associated with greater morbidity (e.g., greater hea lth care utilization, greater functional impairment, poorer quality of life). Most individuals who have limited-symptom attacks have had full Panic Attacks at some time during the course of the disorder. Individuals with Panic Disorder display characteristic concerns or attributions about the implications or consequences of the Panic Attacks. Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., cardiac disease, seizure disorder). Despite repeated medical testing and reassurance, they may remain frightened and unconvinced that they do not have a life-threatening illness. Others fear that the Panic Attacks are an indication that they are "going crazy" or losing control or are emotionally weak. Some individuals with recurrent Panic Attacks Significantly change their behavior (e.g., quit a job, avoid physical exertion) in response to the attacks, but deny either fear of having another attack or concerns about the consequences of their Panic Attacks. Concerns about the next attack, o r its implications, are often associated with development of avoidant behavior that may meet criteria fo r Agoraphobia (see p. 433), in which case Panic Disorder With Agoraphobia is diagnosed.
Panic Disorder
436
Anxiety Disorder!
an almost normal pH). Panic Attacks in response to panic provocation procedures s uch as sodium lactate infusion or carbon dioxide inhalation are more common in individuals with Panic Disorde r than in control subjects or individuals with Generalized Anxiety Disorder. Associated physical examination findings and general medical conditions.
Transient tachycardia and moderate elevation of systolic blood pressure may occur during some Panic AUacks. Studies ha\'e identified significant comorbidity hehveen
Panic Disorder and numerous general medical symptom s and conditions, including. but not limited to, d izziness, cardiac arrhythmias, h yperthyroidism, asthma, chronic obstructive pulmonary disease, and irritable bowel syndrome. However, the nature of the association (e.g., cause-and-effect) between Panic Disorder and these conditions remains unclear. Although studies have suggested that both mitral valve prolapse and thyroid disease are more conunon among individua ls with Panic Disorder than in th e general population, others have found no differences in p revalence.
Preva lence
Although lifetime prevalence rates of Panic Disorder (With or Without Agoraphobia) in community samples have been reported to be as h igh as 3.5%, most studies have found rates between 1% and 2%. One-year prevalence rates are between 0.5% and 1.5%. The prevalence rates of Panic Disorder in clinical samples are considerably higher. For example, Panic Disorder is diagnosed i.n approximately 10% of individuals referred for mental health consu ltation . In general medical settings, preva lence rates vary from 10% to 30% in vestibular, respiratory, and neurology clinics to as high as 60% in cardiology clinics. Approximately one-third to one-half of individuals diagnosed with Panic Disorder in community samples also have Agoraphobia, although a much higher rate of Agoraphobia is encountered in clinical samples.
Cou rse
Age at onset for Panic Disorder va ries considerably, bu t is most typically between late adolescence and the m id-30s. There may be a bimodal distribu tion, with one peak in late adolescence and a second smaller peak in the mid-30s. A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur. Retrospective d escriptions by individuals seen in clinical settings suggest that the usual course
Panic Disord e r
437 1
is chronic but waxing and waning. Some individuals may have episodic outbreaks with years of remission in between, and others may have continuous severe symptomatology. Limited symptom a ttacks may come to be experienced w ith g reater freq uency if the cou rse of the Panic Disorder is chronic. Although Agoraphobia may develop at any point, its onset is usua lly w ithin the first year o f occurrence of recurrent Panic Attacks. The cou rse of Agoraphobia and its relationship to the course of Panic Attacks are variable. In some cases, a decrease or remission of Panic Attacks may be followed dosely by a corresponding decrease in agoraphobic avoidance and anxiety. In others, Agoraphobia may become ch ronic regardless of the presence or absence o f Panic Attacks. Some individuals report that they can reduce the frequency of Panic Attacks by avoiding certain situations. N aturalistic (a llow-up studies of individ uals treated in tertiary care settings (which may select for a poor-prognosis group) suggest that, at 6-10 years posttreatment, about 30% of individuals are well, 40%50% are improved but symptomatic, and the remaining 20%-30% ha ve symptoms that are the same or slightly worse.
Familial Pattern
First-degree biological relatives of indiv iduals w ith Panic Disorder are up to 8 times more li kely to dcvclop Panic Disorder. If the age at onset of the Panic Disorder is before 20, first-degree relatives have been found to be up to 20 times marc likely to have Panic Disorder. However, in clinical settings, as many as one-half to three-quarters of individuals with Panic Disorder do not have an affected firs t-degree biological elative. Twin studies indica te a genetic contribution to the development of Panic Disorder.
Differential Diagnosis
Panic Disorder is not diagnosed if the Panic Attacks are judged to be a direct physiological consequence of a general m edical condition, in which case an Anxiety Disorder Due to a General Medical Condition is diagnosed (see p. 476). Examples of general medical conditions that can ca use Panic Attacks includ e hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular d ysnmctions, seizure disorders, and cardiac conditions (e.g., arrhythmias, supraventricular tachycardia). Appropriate laboratory tests (e.g., serum calcium levels for hyperpa rathyroidism) o r phySica l examinations (e.g., for cardiac conditions) may be helpfu l in determining the etiological role of a general medical condition. Panic Disorder is not diagnosed if the Panic Attacks are judged to be a direct physiological consequence of a substance (i.e., a drug of abuse, a medication), in which case a Substance-Induced Anxiety Disorder is di agnosed (see p. 479). Intoxica tion w ith central nervous system stimu lants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a Panic Attack. However, if Panic Attacks continue to occur outside of the context of substance use (e.g., long after the effects of intoxication or withdrawal have ended), a diagnosis of Panic Disorder should be considered. In addition, because Panic Disorder may p recede substance use in some individuals and may be associated w ith increased substance use for purposes of self-medication, a detailed history should be taken to determine
438
Anxiety Disorders
if the individual had Panic Attacks prior to excessive s ubstance use. If this is the case, a d iagnosis of Panic Disorder sh ould be considered in addition to a diagnosis of Substance Dep endence or Abuse. Features such as onset after age 45 years or the presence of atyp ica l symptoms during a Panic Attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control , headaches, slurred sp eech, or amnesia) sugges t the possibil ity that a general medicaJ condition or a subs tance may be causing the Pan ic Attack symptoms. Panic Disorder m u st be distingu ished from other mental disorders (e.g., other Anxiety Disorders and Psychotic Disorders) that have Panic Attacks as an associated feature. By definition, Panic Disorder is characterized by recurrent, unexpected (spontaneous, unwed , "out o f the blue") Panic Attacks. As discussed earlier (see p . 430), there are three types of Panic Attacks-unexpected, situa tionally bound, and situationally predisposed . The presence of recurrent unexpected Panic Attacks either initially or later in the course is required for the diagnosis of Panic Disorder. In contras t, Panic Attacks that occur in the context of other Anxiety Disorders are situationa lly bound or situationally p redisposed (e.g., in Social Phobia cued by social situations; in Specific Phobia cued by an object or situation; in Gen eralized Anxiety Disorder cued b y worry; in Obsessive-Compulsive Disorder cued by though ts of or exposu re to the object or situation related to an obsession (e.g., exposure to dirt in someone with an obsession about contamination); in Posttraumatic Stress Disorder cued by s timuli recalling the s tressor). In some cases, the individ ual may have d ifficulty identifying cues triggering a Panic Attack. For example, an ind ividual with Posttraumatic Stress Diso rder may have a Panic Attack triggered by cognitions or physiological symptoms similar to those that occurred at the time of the traumatic event (e.g., cardiac arrhy thmias, feelings of detachment). These cues may not be easily associated by the individual w ith the triggering event. If the Panic Attacks occur on ly in situations that can be associated with the traumatic event, then the Panic Attacks sho uld be attributed to the Posttraumatic Stress Disorder. For example, if a person who had been raped w hil e at home alone experiences ranic Attacks only when others are not around, a d iagnosis o f Posttraumatic Stress Disorder should be considered instead of a diagnosis of Panic Disorder. However, if the person experiences u nexpected Panic Attacks in other situations, then an additional d iagnosis of Panic Disorder should be considered. The focus of the anxiety also helps to differentiate Panic Disorder With Agoraphobia from other disorders characterized by avoidant behaviors. Agoraphobic avoidance is associated w ith anxiety about the possibili ty of having a Panic Attack or panic-like sensations, whereas avoidance in other disorders is associated w ith concern about the nega tive or harmfu l consequences arising from the feared object or situation (e.g ., scrutiny, humiliation, and embarrassment in Social Phobia; fa lling from a high place in Specific Phobia o f heigh ts; sepa ration from parents in Separation Anxiety Disorder; persecution in Delusional Disorder). Differentiation of Specific Phobia, Situationa l Type, from Panic Disorder With Agoraphobia may be particularly difficult because both disorders may include Panic Attacks and avoidance of similar types of situations (e.g., driving, flying, public transp ortation, enclosed places). Prototypically, Panic Disord er With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multip le siruations thoug ht to be likely triggers of the Panic Attacks.
Panic Disorder
439
Pro totypically, Specific Phobia, Sih.ta tio nal Type, is cha racterized by s ituational avoidance in the absence of recurrent unexpected Pa nic A ttacks. Some presentations fall between these prototypes and require clinical judgment in the selection of the most app ropriate diagnosis . Four factors can be helpful in m aking this judgment: the focu s of a nxiety, the type and number of Panic Attacks, the numbe r of situations avoided, and the level of interc urren t anxiety. Fo r example, an indi vidual w ho ha d not previously feare d o r a voided elevators has a Panic Attack in a n e levator and begins to dread going to work because of the need to take the elevator to his office on the 24th noor. If this individual subsequently has Panic A ttacks only in e levators (even if the focu s of anxiety is on the Panic Attack), the n a diagnosis of Specific Phobia may be appropriate. If, however, the ind iv idual experiences unexpected Panic Attacks in o the r situations and begins to avoid or endure with dread o ther situations because of anxious anticipation of a Panic Attack, then a diagnosis of Panic Disorder With Agoraphobi a w ould be warranted. Furthermore, the presence of pervasive apprehension abou t having a Panic Attack even when not anticipating exp osure to a phobic situa tio n also su pports a di agnosis of Panic Disorder \>\Iith Agoraphobia. II the individual has additional unexpected Panic A ttacks in other s ituations but no additional avoidance o r e ndurance with dread develops, then the appropria te diagnosis would be Panic Disorder W ithout Agoraphobia. If the focus of avoidance is not related to having a Panic Attack but concerns som e othe r catastrophe (e.g., injury due to the elevator cable breaking), then an additional d iagnosis of Specific Phobia m ay be considered. Simila rly, dis tinguishing between Social Phobia and Panic Disorder W ith Agoraphob ia can be difficult, esp ecially when there is a voidance on ly of socia l situatio ns. For example, individuals with Panic Disorder With Agoraphobia and those with Social Phobia may both avoid crowded s ituations (e.g., large sho pping centers, crowded parties). The focus of anxiety and the type o f Panic A ttacks can be helpful in making this dis tinction. For example, an individua l who had not previously had a fear of public speaking has a Panic Attack while g iving a talk and begins to dread giving presentations. II this indiv idual su bsequently h as Panic Attacks o nly in social performance situations and if these attacks are accompanied by a fear of being embarrassed and humiliated, then a d iagnosis of Social Phobia may be appropriate. If, however, the individua l continues to experience unexpected Panic Attacks in o ther Situations, then a diagnosis of Panic Disorder With Agoraphobia would be warra nted . Individuals with Social Phobia fear scrutiny and rarely have a Panic Attack w he n alone (unless when anticipating a social situation), w hereas individuals w ith Panic Disorder W ith Agoraphobia may be more anxious in s ituations where they must be w ithou t a trusted compa nion. In addition, nocturnal Panic Atlacks that awaken an individual from sleep are characteristic of Panic Disorder. When criteria are met for bo th Panic Disorder and another Anxiety or Mood Disorder, both disorders should be diagnosed. However, if unexpected Panic A ttacks occur in the context of another disorder (e.g., Major Depressive Disorder or Generalized Anxiety Disorder) but are not accompanied by a month or more o f fear of having additional attacks, associated concerns, o r behavior change, the additional diagnosis of Panic Disorder is not made. Because individuals with Panic Disorder may self-me dicate their symptoms, comorbid Substance-Rela te d Disorders (most notably related to cannabis, alcohol, and cocaine) are not uncommon.
l
440
Anxiety Disorders
C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g ., hyperthyroid
ism).
D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e .g., on exposu re to a specific phobic situation). ObsessiveCompulsive Disorder (e.g ., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g ., in response to being away from home or close relatives).
300.22
441
a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroid ism) . D. The Panic Attacks are not better accounted for by another mental disorder, such as Socia l Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g ., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g ., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e .g ., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g ., in response to being away from home or close relatives).
442
Anxiety Disorders
symptoms (e.g., fa inting) is clea rly in excess of that usu ally associa ted with the condition (Criterion D). When a diagnosis of Agoraphobia ',\Iithout History of Panic Disorder is being made, it should be ensured tha t the avoid,mce is characteris tic of Agoraphobia and cannot be better explained by ano ther Axis I disord er (e.g., Specific Phobia or Soc ial Phobia) or Axis U disorder (e.g., Avoidant Personality Disorder).
Preva lence
in clinica l settings, almost all individuals (over 95%) w ho present w ith Agora phobia also have a current diagnosis (or hislory) of Panic Disorder. In contrast, the prevalence of AgoraphObia Without Hislory o f Panic Disorder in epidemiological samples has been reporled 10 be higher than that for Panic Disorder With Agoraphobia. However, problems with assessment appear to have inflated the rates reported in epid emiological stud ies. Recently, indi vidu als who were given a diagnosis of Agoraphobia Without History of Panic Disorder in an epidemiological study were reevaluated by clinicians using standard interview schedules. The majority were found to have Specific Phobias, but not Agoraphobia.
Course
Rel<1tively little is known about the course of Agoraphobia 'N ithout History of Panic Disorder. Anecd otal evidence suggests that some cases may persist for years and be associated with consid erable impa irment.
Differential Diagnosis
Agoraphobia Without H.istory of Panic Disorder is distinguished ITom Pan ic Disorder With Agoraphobia by the absence of a h istory of recurrent unexp ected Panic Attacks. The avoidance in Agoraphobia Without History of Panic Disorder results from fear of incapacitation or humiliation due to unpredictable, sudden, panic-like symptoms rather than from fea r of a full Pan ic Attack as in Panic Disorder With Agoraphobia. The diagnosis of Panic Disorder With Agoraphobia remains appropriate in cases in which Panic Attacks go into remission but Agoraphobia continues to be experienced. Other reasons for avoidance must also be distinguished from Agoraphobia Without H.istory of Panic Disorder. In Social Ph obia, individua ls avoid social or perfor mance situations in which they fear that they might act in a way that is humiliating or embarrassing. In Sp ecific Phobia, the ind ividual avoids a specific feared object or situation . In Majo r Dep ressive Disorder, the individual may avoid leaving home due to apathy, loss of energy, and anhedonia . Persecutory fears (as in Delusional Diso rder) and fears of contamination (as in Ob sess ive -Compulsive Disorder) can
300 .29
443
also lead to w idesp read avoidance. In Separatio n Anxiety Disorder, children avoid situations tha t take them away from home or dose relatives. lndividuals with certain general medical cond itions may avoid situations due to realis tic concerns about being incapaci tated (e.g., fainting in an individual w ith transient isch emic attacks) or being embarrassed (e.g., d iarrhea in an individual w ith Ccohn's d isease). The d iagnosis of Agoraphobia Without His tory of Panic Disorder should be given only if the fear or avoidance is dearly in excess of th at u sually associated w ith the general m edical condition .
(e.g ., a drug of abuse. a medication) or a genera l medical conditi on. D. If an associated general medical condition is present. the fear described in Criterion A is clearly in excess of t hat usually associated with the cond ition.
Anxiety Disorders
The individual experiences a marked, persistent, and excessive or lUlreasonable fear when in the presence of, or when anticipating an encowlter with, a specific object or situation. The focus of the fear may be anticipated harm from some aspect of the object or situation (e.g., an indiv idual may fear air travel because of a concern about crashing, may fear dogs because of concerns about being bitten, or may fear driving becau se of concerns about being hi t by other vehicles on the road). Specific Phobias may also involve concerns about losing control, panicking, somatic manifestations of a nxiety and fear (such as increased heart rate or shortness of breath), and fainting that might occur on exposure to the feared object. Forexample, individuals afraid of blood and injury may also worry about the possibility of fainting; people afraid of heigh ts may also worry abou t dizziness; and people afraid of closed-in situations may also worry about losing control and screaming. These concerns may be particularly strong in the Situational Type of Specific Phobia. Anxiety is almost invariably felt immediately on confronting the phobic stimulus (e.g ., a person with a Specific Phobia of cats will almost invariably have an immedia te anxiety response when forced to confront a cat). The level of anxiety or fear usually varies as a function of both the degree of proximity to the phobic s timulus (e.g ., fear intensifies as the cat approaches and decreases as the cat withdraws) and the degree to which escape from the phobic stimulus is limited (e.g., fear intensifies as the elevator approaches the midway point between floors and decreases as the doors open at the next floor). However, the intensity of the fear may not always relate predictably to the phobic stimulus (e.g., a person afraid of heights may experience variable amounts of fear when crossing the same bridge on different occasions). Sometimes full-blown Panic Attacks are experienced in response to the phobic stimulus, especially when the person must remain in the situation or believes that escape will be impossible. Occasionally, the Panic Attacks are delayed and do not occur immediately upon confronting the phobic stimulus. This dela y is more li kely in the Situational Type. Because marked anticipatory anxiety occurs if the person is confronted with the necessity of entering into the phobic situation, such situations are usually avoided. Less commonly, the person forces himself or herself to endure the phobic situation, but it is experienced with intense anxiety. Adults with this disorder recognize that the phobia is excessive or lUU"easonable. The diagnosis would be Delusional Disorder instead of Specific Phobia for an individual who avoids an elevator because of a conviction that it has been sabotaged and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being shot in a hunting area or a dangerous neighborhood). Insight into the excessive or unreasonable nature of the fear tends to increase with age and is not required to make the diagnosis in children. Fears of circumscribed objects or situations are very common, especially in children, but in many cases the degree of impairment is insufficient to warrant a diagnosis. If the phobia does not significantly interfere with the individual's functioning or cause marked distress, the diagnosis is not made. For example, a person who is afraid of snakes to the point of expressing intense fear in the presence of snakes wowd not receive a diagnosis of Specific Phobia if he or she lives in an area devoid of snakes, is not restricted in activities by the fear of snakes, and is not d istressed about having a fear of s nakes.
300 .29
Subtypes
The following subtypes may be specified to indica te the focus of fea r or avoidance in Specific Phobia (e.g., Specific Phobia, Animal Typ e) . Animal Type. This subtype should be specified if the fea r is cued by animals or insects. This subtype generally has a childhood onset. Natural Environment Type. This subty pe should be speci fi ed if the fear is cued by objects in the namral environment, such as storms, heights, or water. This subtype generally has a childhood onset. Blood-Inj ection-Inju ry Type. nus subtype should be specified if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly fami lial and is often characterized by a strong vasovagal response. Situation al Type. This sub type should be specified if the fear is cued by a specific situation such as public transportation, hmnels, brid ges, elevators, fi ying, driving, or enclosed places. This subtype has a bimoda l age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. nus subtype appears to be similar to Panic Disorder With Agoraphobia in its characteristic sex ratios, famili al aggregation pattern, and age at onset. Other Type. This subtype should be specified if the (ear is cued by other stimu li. These stimuli might include the fear of choking, vomiting, or contracting an iUness; "space" phobia (Le., the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters. The frequency of the subtypes in adult clinical settings, fro m most to least frequent, is Situational; Natural Environment; Blood-Injection-Injury; and Animal. Smdies of community sam ples show a slightly different pattern, with phobias of heights and of spiders, mice, and insects most common, and phobias of other animals and other elements of the natural environment, such as storms, thunder, and lighming, least common. Phobias of d osed-in situati ons (a Situational Type of phobia) may be more common in the elderly. In many cases, more than one subtype of Specific Phobia is present. Having one phobia of a specific subtype tends to increase the likelihood of ha ving another phobia from within the same subty pe (e.g., fear of cats and snakes). When more than one subtype applies, they should all be noted (e.g., Specific Phobia, Animal and Natural Environment Types).
Anxie ty Disorders
er among individuals with earlyonset Specific Phobias. In clinical settings, Specific Phobias are very common comorbid diagnoses w ith other d isorders. However, Specific Phobias are rarely the focus of clinical a ttention in these situations. The Specific Phobia is usually associated w ith less d istress or less interference w ith functiOning than the comorbid main diagnosis. Overall, only 12%-30% are estimated to seek professional help for their Specific Phobias. In the absence of other d iagnoses, help seek ing for Specific Phobias is more likely with more fun ctionally impairing phobias (e.g., phobias of objects o r situa tions that are co mmonly encountered). multiple phobias, and Panic Attacks in the phobic context. In contrast, individuals w ith irrational fea rs of blood injury, med ical procedures, and medical settings may be less likely to seek help for p hobias.
Associated physical examination findings and general medical conditions. A vasovagal fainting response is characteristic of Bloodlnjection Injury Type Specific Phobias; approximately 75% of such individuals report a history o f faintin g in these situations. The physiological response is characterized by an initial brief acceleration o f heart rate and elevation in blood p ressure followed by a deceleration of heart rate and a drop in blood pressure, which contrasts w ith the usual acceleration of heart rate and elevation in blood pressure in other Specific Phobias. Certain general medica l conditions may be exacerba ted as a consequence of phobic avoidance. For ex ample, Specific Phobias, BloodInjection-Inju ry Type, may have d etrimen tal effects on dental or physical health, because the individual may avoid obtain ing necessary medical care. Similarly, fears of choking may have a detrimental effect on health when food is limited to substances that are easy to sw allow or when ora l med ication is avoided .
300.29
Prevalence
Although phobias are common in the general population, they rarely result in sufficient impairment or distress to warrant a diagnosis of Specifi c Phobia. The reported prevalence may vary depending on the threshold used to determine impairment or distress and the number of types of phobias surveyed. In community sam ples, CUfrent prevalence rates range from 4% to 8.8%, and lifetime prevalence rates range from 7.2% to 11.3%. Prevalence rates decline in the elderly. Also, prevalence estimates vary for different types of Specific Phobias.
Course
The firs t symptoms of a Specific Phobia usually occur in childhood o r early adolescence and may occur at a younger age for women than for men. Also, the mean age at onset varies according to the type of Specific Phobia. Age at onset for Specifi c Phobia, Situational Type, tends to be bimodaUy distributed, w ith a peak in childhood and a second peak in the mid-20s. Specific Phobias, 1 atural Environment Type (e.g., height phobia), tend to begin primarily in childhood, although many new cases of height phobia d evelop in early adulthood. The ages a t onset for Specific Phobias, Animal Type, and for Specifi c Phobias, Blood-Injection-Injury Type, are also usually in childhood . Fear of a stimulus is usually present for some time before becoming sufficiently distressing or impairing to be considered a Specific Phobia. Predisposing factors to the onset of Specific Phobias include traumatic events (such as being attacked by an animal or trapped in a closet), unexpected Panic Attacks in the to-be-feared situation, observation of others undergoing trauma or d emonstrating fearfulness (such as observing o thers fall from heights or become afraid in the presence of certain animals), and informational transmission (e.g., repeated parental warnings about the dangers of certain animals or media coverage of airplane crashes). Feared objects or situations tend to involve things that may actua lly represen t a threat or have represented a threat at some point in the course of human evolution . Phobias that result from traumatic events o r unexpected Panic Attacks tend to be particularly acute in their development. Phobias of traumatic origin do not have a characteristic age at onset (e.g., fear of choking, which usually follows a choking o r near-choking incident, may develop at almost any age). Specific Phobias in adolescence increase the chances of either persistence of the Specific Phobia or development of additional Specific Phobias in early adulthood but do not predict the d evelopment of other disorders. Phobias that persist into adulthood remit only infrequently (around 20% of cases).
Familial Pattern
There is an increased risk for Specific Phobias in famil y members of those with Specific Phobias. Also, there is some evidence to sugges t that there ma y be an aggregation within families by type o f phobia (e.g., first-degree biological relatives of persons with Specific Phobias, Animal Type, are likely to have animal phobias, although not necessarily of the same animal, and first-degree biological relatives of persons with Specific Phobia s, Situational Type, are likely to have phobias of sihlations). Fears of blood and injury have particula rly strong familia l patterns.
Anxiety Disorders
Differential Diagnosis
Specific Phobias differ from most other Anxiety Disorders in levels of intercurrent anxiety. Typically, individuals with Specifi c Phobia, unlike those with Panic Disord er With Agoraphobia, do not presen t with pervasive anxiety, because their fear is limited to specific, circumscribed objects or situations. However, generalized anxious anticipation may emerge under conditions in which encounters with the phobic stimulus become mo re likely (e.g., when a person who is fearful of snakes moves to a d esert area) o r when life events force immediate confrontation w ith the phobic stimulus (e.g., when a person who is fearful of flying is forced by circumstances to fly). Differentiation of Specific Phobia, Situational T}rpe, from Panic Disorder With Agoraphobia may be particularly difficult because both disorders may include Panic Attacks and avoidance of similar types of situations (e.g., driving, flying, public transportation, and enclosed places). Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Prototypically, Specific Phobia, Situational Type, is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks. Some presentations fall beh\'en these prototypes and require clinical judgment in the selection of the most appropriate diagnosis. Four factors can be helpful in making this judgment: the focus of fear, the type and nu mber of Panic Attacks, the number of situations avoided, and the level of intercurrent anxiety. For example, an individual who had not previously feared or avoided elevators has a Panic Attack in an eleva tor and begins to dread going to work because of the need to take the elevator to his office on the 24th floo r. If this individual subsequently has Panic Attacks only in elevators (even if the focus of fear is on the Panic Attack), then a diagnosis of Specific Phobia may be appropriate. It however, the ind ividual experiences unexpected Panic Attacks in other situations and begins to avoid or endure with dread other sihlations because of fear of a Panic Attack, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. Furthermore, the presence of pervasive apprehension about having a Panic Attack even when not anticipating exposure to a phobic situation also supports a d iagnosis of Panic Disorder With Agoraphobia. If the individual has additional unexpected Panic Attacks in other situations but no additional avoidance or endurance with d read develops, then the appropriate diagnosis would be Panic Disorder Without Agoraphobia . Concu rrent diagnoses of Specific Phobia and Panic Disorder With Agoraphobia are sometimes w arranted . In these cases, consideration o f the focus of the individual's concern abou t the phobic situation may be helpful. For example, avo idance of being alone because of concern abou t ha ving unexpected Panic Attacks warrants a diagnosis of Panic Disorder With Agoraphobia (if other criteria are met), whereas the additional phobic avoidance of air travel, if due to worries about bad weather conditions and crashing, may warrant an additional diagnosis of Specific Phobia. Specific Phobia and Social Phobia can be differentiated on the basis of the focus of the fears. For example, avoidance of eating in a r~sta urant may be based on concerns about negative evaluation fro m others (i.e., Social Phobia) or concerns about choking (i.e., Specific Phobia). In contrast to the avoidance in Specific Phobia, the avoidance in Posttraumatic Stress Disorder follows a life-threa tening stressor and is accompa-
300.29
nied by additional feature s (e.g., reexperie.n cing the trauma and restricted affect). In ObsessiveCompulsive Disorder, the avoidance is associated with the content of the obsession (e.g ., dirt, contamination). In individuals with Separation Anxiety Disorder, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to fears of separation from persons to whom the individual is attached . Moreover, children with Separation Anxiety Disorder often ha ve associated exaggerated fears of people or events (e.g., of muggers, burglars, kidnappers, car acciden ts, airplane travel) that might threaten the integrity of the family. A separate diagnosis of SpecUic Phobia would rarely be warranted . The differentiation between H ypochondriasis and a Specific Phobia, Other Type (i.e., avoidance of situations that may lead to contracting an illness), depends on the presence or absence of disease conviction. Individuals with H ypochondriasis are preoccupied w ith fears of having a disease, w hereas individuals wi th a Specific Phobia fear con tracting a disease (but do not believe it isaJready present). ln ind ividuals with Anorexia Nervosa and Bulimia Nervosa, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues. An individual w ith Schizophrenia or another Psychotic Disorder may avoid certain activities in response to delusions, but does not recog nize that the fear is excessive or unreasonable. Fears are very common, particularly in childhood, but they do not warrant a diagnosis of Specific Phobia unless there is significant interference with social, educational, or occupational functioning or marked distress about having the phobia .
Note: In children,
D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) function ing, or social activities or relationships, or there is marked distress about having the phobia. F. In individuals under age 18 years, the duration is at least 6 months .
Anxiety Disorders
Animal Type Natural Environment Type (e.g., heights, storms, water) Blood-Injection-Injury Type Situational Type (e.g., airplanes, elevato rs, enclosed places) Other Type (e.g., fear of choking, vomiting, o r contracting an ill ness; in chi ldren, fea r of loud sounds or costumed characters)
300.23
451
that others w ill notice their trembling hands or voice or they may experience extreme anxiety when conversing with others becatlse of fear that they will appear inarticulate. They may avoid eating, drinking, or w riting in public because of a fear of being embarrassed by having o thers see their hands shake. Individuals with Social Phobia almost always experience symptoms o f anxiety (e.g., palpitations, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension, blushing, confusion) in the feared social situations, and, in severe cases, these symptoms may meet the criteria for a Panic Attack (see p. 432). Blushing may be more typical of Social Phobia . Adults with Socia l Phobia recognize that the fear is excessive or Wlfeasonable, although this is not always the case in child ren. For example, the d iagnosis would be Delusional Disorder instead of Social Phobia for an indi vidual who avoids eating in public because of a conviction that he or she w ill be observed by the p olice and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g ., fear of being caUed on in class when unprepared). The person w ith Social Phobia typically will avoid the feared situations. Less commonly, the person forces himself o r herself to endure the social or performance situation, but experiences it with intense anxiety. Marked anticipatory anxiety may a lso occur far in advance of upcoming social or public situations (e.g., worrying every day for several w eeks before attend ing a social event). There may be a vicious cycle of anticipatory anxiety leading to fearful cognition and anxiety symptoms in the feared situa tions, w hich leads to actual or perceived poor performance in the feared situations, w hich leads to embarrassment and increased anticipatory anxiety abou t the feared situations, and so on. The fear or avoidance mus t interfere significantly with the person' s normal routine, occupational or academic fun ctioning, or social activities or relationships, or the person must experience marked d is tress about having the p hobia. For example, a person who is afraid of speaking in public would not receive a diagnosis of Social Phobia if this activity is not routinely encountered on the job or in the classroom and the person is not particularly distressed about it. Fears of being embarrassed in social situations are common, but us ually the degree of distress or impairment is insufficient to warrant a diagnosis of Social Phobia. Transien t social anxiety or avoidance is especially common in childhood and adolescence (e.g., an adolescent girl may avoid ea ting in front of boys for a short time, then res ume us ual behavior). In those younger than age 18 years, only symptoms that persist for at least 6 months qualify for the diagnosis of Social Phobia.
Specifier
Generalized. This specifier can be used when the fears are related to most social si tuations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority fi gures, attending parties). lndividuals w ith Social Phobia, Generalized, usually fear both public performance situations and social interactional situations. Beca use individuals w ith Social Phobia often do not spon taneously report the full range o f their social fears, it is useful for the clinician to review a list of social and performance situations with the individual. Individuals whose clinical manifestations do not meet the
Anxiety Disorders
d efi n ition of Generalized compose a heterogeneous group (sometimes referred to in the literature as nongeneralized, circumscribed, or specific) that includes persons who fear a single performance siltlation as well as those who fea r several, but n ot most, social situations. Individuals w ith Social Phobia, Generalized , may be more likel)' to man ifest deficits in social skills and to have severe social and work impairment.
300.23
and may be unable to identify the nature of their anxiety. There may be a decline in classroom performance, sch ool refu sal, or avoidance of age-appropriate socia l activities and dating. To make the diagnosis in children, there must be evidence of capacity for social relations hips with famili ar people and th e social anxiety must occur in peer settings, not jus t in interactions with adults. Because of the disorder's early onset and chronic course, impairment in child ren tends to take the form of failure to achieve an expected level of functioning, rather than a decline from an optimal level of functioning. In contras t, w hen the onset is in ado lescence, the disorder may lead to decremen ts in social and academic performance. Epidemiological and community-based s tudies suggest tha t Socia l Phobia is more common in women than in men . In mos t clinical samples, however, the sexes are either equally represented or the majority a re male.
Course
Social Phobia typically has an onset in the mid-teens, sometimes emerging out of a childhood history o f social inhibition or s hyness. Some individuals report an onset in ea rly childhood. O nset may abruptly follow a s tressful or hu miliating experience, or it may be insidious. TIle course of Social Phobia is often continuous. Duration is frequently lifelong. although the d isorder may attenuate in severity or remit during adulthood. Severity of impairment may fluctuate with life slressors and demands. For example, Social Phobia may diminish afler a person with fear of dating marries and reemerge after death of a sp ou se. A job promotion to a position requiring public speaking may resu lt in the emergence of Social Phobia in someone who previo usly never needed 10 speak in public.
Familial Pattern
Socia l Phobia appears to occur more frequentl y among firs t-degree biologica l relatives of those with the disord er compared wi th the general population . Evidence for this is strongest for the Genera lized s ubtype.
Anxiety Disorders
Differential Diagnosis
Individuals w ith both Panic A ttacks and social a voi dance sometimes p resent a p otentially d iffi cult diagnostic p roblem. Prototyp ically, Panic D is order With Agoraph obi a is characterized by the initial onset of unexpected Panic Attacks and the s ubsequent avoidance of multiple s ituations thou ght to be likely triggers of the Panic A ttacks. Although social situations m ay be avoided in Panic Disorder due to the fear of being seen w hile ha\'ing a Panic A ttack, Panic Disorder is characterized by recurrent unexpected Panic Attacks tha t are not limited to social situations, a nd the diagnosis of Social Phobia is not m ade w hen the only social fear is o f being seen w hile having a Panic A ttack. Pro totypically, Social Phobia is characterized by the avoidance o f social situations in the absence of recurrent unexpected Pan ic A ttacks. When Panic A ttacks do occu r, they take the form o f situationaHy bound or s ituationally p red isposed Panic Attacks (e.g., a person w ith fea r of embarrassm ent w hen sp eaking in p ublic experiences Panic A ttacks cued only by public sp eaking or o ther social situations). Some presentations fall between these prototypes and require clinical judgment in the selection of the most appropriate d iagnosis. For example, an individual who had not p reviously had a fear of public speaking has a Pan ic A ttack w hile g iving a talk an d begins to d read giving presenta tions. if this individual s ubsequently has Panic A ttacks only in social p erformance s ituations (even if the focus of fear is on the panic), then a d iagnosis of Social Phobia may be a ppropria te. If, however, the individual continues to exp erience unexpected Panic Attacks, then a diagnosis of Panic Disorder With Agora phobia would be war ranted. If criteria are m et for both Social Phob ia and Panic Disorder, both d iagnoses may be given. For example, an individual with Welong fear and avoidance o f most social s itua tions (Social Phobia) later d evelops Panic Attacks in n onsocial situations and a variety of add itional avoidan ce beh aviors (Panic Disorder With Agoraphobia). Avoidance of situa tions because of a fear of p ossible humiliation is highly prominent in Social Phobia, but may also at times occur in Pani c Disorder With Agoraphobia and Agoraphobi a Withou t His tory of Panic Dis order. The s ituations avoided in Social Phobia are li mited to those invoh'ing possible scru tiny by o ther p eople. Fears in Agoraphobia Without History of Panic Disorder typically involve characteristic dusters of s ituations that mayor m ay not involve scrutiny by others (e.g., being alone outside the home or being home alone; being on a bridge or in an ele\ator; traveling in a bus, train, automobile, or airplane). The role of a companion also may be usefu l in distinguishing Social Ph obia from Agoraphobia (With and W ithout Panic Disorder). Typically, individ uals with agora phobic avoidance pre fer to be with a trusted companion w hen in the feared situation, w hereas individuals w ith Social Phobia may have marked anticip atory anxiety, but characteristically do n ot have Panic A ttacks when alone. A person w ith Social Phobia w ho fea rs crowded s tores would feel scru tinized with or without a companion and might be less anxious without the added burden o f perceived scrutiny by the companion . Chi ldren with Separation Anxiety Disorder m ay avoid social settings d ue to concerns abou t being separated from their caretaker, cqncem s a bout being embarrassed by needing to leave prematurely to return h ome, or concerns abou t requiring the p resence of a parent w hen it is not developmentally a pprop riate. A separate d iagnosis of Social Phobia is generaUy not warranted . C hildren w ith Separati on Anxiety Dis
300.23
455
order are usually comfortable in social settings in their own home, whereas those wi th Social Phobia di splay signs of d iscomfort even when feared social situations occur at home. Although fear of embarrassm ent or humiliation may be presen t in Generalized Anxiety Di sorder or Specific Phobia (e.g., embarrassmen t about fainting when having blood drawn), this is no t the main focus of the individual's fear or anxiety. Children w ith Generalized Anxiety Disorder have excessive worries about the q uality of their performance, but these occur even w hen they are not evaluated by others, whereas in Social Phobia the potential evaluation by o thers is the key to the anxiety. In a Pervasive Developmental Disorder and Sch izo id Personality D isord er, socia l situations are avoided because of lack of in terest in relating to other individ uals. In contras t, ind ividuals with Social Phobia have a capacity for and interest in social relationships wi th fami Har people. In particular, for children to qualify fo r a diagnosis of Social Phobia, they must have at least one age-approp riate social relationship w ith someone ou tsid e the immediate famil y (e.g., a child w ho feel s uncomfortable in sodal gatherings with peers and avoid s such situations, but who has an active interest in and a relationsh ip with one famili ar same-age friend). Avoid ant Personality D isord er shares a number o f features w ith Social Phobia and ap pears to overlap extensively with Social Phobia, Generalized. Avoidant Personality Disord er may be a more severe variant of Social Phobia, Generalized , that is not qualitatively distinct. For ind ividuals with Social Phobia, Generalized, the additional d iagnosiS of Avoid ant Personality Disorder should be considered. Social anxiety and avoidance of social situations are associated features of many other m en tal d isorders (e.g., Major Depressive Disorder, Dysthymic Disorder, Schizophrenia, Body Dysmorphic Disorder). U the symptoms of social anxiety or avoidance occur only du ring the course of ano ther mental d isord er and are judged to be better accoun ted for by that disorder, the additional diagnosis of Social Phobia is no t m ade. Some individuals may experience clinically significan t social anxiety and avoidance related to a general medjcal condition or mental disord er w ith potentially embarrassing symptoms (e.g., tremor in Parkinson's disease, Stuttering, obesity, strabismus, facial scarring, or abno rmal eating behavior in Anorexia Nen 'osa). However, if social anxiety and avoidance are limited to concems abou t the general m edical condition or mental disorder, by convention the diagnosis o f Social Phobia is not made. If the social avoidance is clinically signifi cant, a separate d iagnosis o f Anxiety Disorder No t Othen vise Specified rna}' be given. Performance anxiety, stage fri gh t, and shyness in social situations that involve unfamiliar people are common and should not be d iagnosed as Social Phobia unless the anxiety or avoidance leads to clinically significant impairment or m arked distress. Children comm only exhibit socia l anxiety, particularly when interacting w ith Wlfamiliar adults. A diagnOSiS o f Socia l Phobia should not be made in child ren unless the social anxiety is also ev ident in peer settings and persists for at least 6 months.
A nxiet y Disorders
D. The feared socia l o r perfo rmance situations are avoided o r e lse a re endured with intense a nxiety o r distress. E. The avoidance, a nxious ant iCipation, o r distress in t he feared social o r performa nce situation(s) interferes significantly with the person's normal ro utine, occupational (academic) functi o ning, or soc ial activities or relatio nships, o r there is marked distress about having the phobia. F. In ind ividuals unde r age 1B years, the duration is at least 6 months.
G. The fea r or avoidance is no t d ue to the direct physiolog ical effects of a substance
(e.g., a drug of abuse. a medication) or a general medical condit ion and is not bette r accounted fo r by another mental disorder (e.g ., Panic Disorder With o r Without Agoraphobia. Separation Anx iety Disorder, Body Dysmorph ic Disorder, a Pervasive Developmental Disorder, o r Schizoid Personal ity Disorder).
H. If a genera l medical condition or another mental disorder is present, the fear in Cri-
te rion A is unrelated to it, e .g., the fea r is not of Stuttering, t rembling in Parkinson's disease, o r exhibiting abnormal eating behavior in Anorexia Nervosa o r Bulimia Nervosa .
Specify if:
Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)
300. 3
300.3
Obsessive-Compulsive Disorder
terion C) . A t some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Criterion B). 1I another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (C riterion D). The disturbance is not due to the direct physiological effects of a subs tance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion E). Obsessions a re persistent ideas, thoughts, impulses, or images that are experienced as intrusive a nd inappropria te and that cause marked anxiety or distress. The intrusive and inappropriate quality of the obsessions has been referred to as "ego-dystonic." This refers to the individual's sen se that the content of the obsession is alien, not wi thin his or her own control, a nd not the kind of thought thai he or she would expect to have. H owever, the individual is able to recognize that the obsessions a re the p roduct of his or her own mind and are not imposed from w ithout (as in thought insertion). The most common obsessions are repeated thoughts about contamina tion (e.g., becoming contaminated by s haking hands), repea ted d oubts (e.g., wondering whether one has performed s ome act s uch as hav ing hurt someone in a traffic accident or ha ving left a door unlocked), a need to have things in a particular order (e.g., intense distress when objects are disordered or asymmetrical), aggressive or horrific impulses (e.g., to hurt one's child or to s hout an obscenity in church), and sexual imagery (e.g., a recurrent pornogr<1phic image). The thoughts, impulses, or images are not simply excessive worries about real-life problems (e.g., concerns about current ongoing difficulties in life, s uch as financial, work, or school problems) and are unlikely to be related to a real-li fe p roblem. The individual with obsessions u sually attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., a compulsion). For example, an individual plagued by doubts about having turned off the stove attempts to n eu tralize them by repeatedly checking to ensure that it is off. CompulsioJ/s a re repetitive behaviors (e.g., hand washing, ordering, checking) or me ntal acts (e.g., p ra ying, cOlmting, repeating word s silently) the goal of which is to prevent o r reduce anxiety or dis tress, nollo provide pleasure or g ra tification. In most cases, the person fee ls driven to perform the compuls ion to reduce Ihe distress that accompanies an obsession or to prevent some dreaded e vent or s ituation. For example, individuals with obsessions about being contaminated may reduce their menta l distress by washing their hands until their skin is raw; individuals distressed by obsessions a bout having left a door unlocked may be driven to check the lock every few minutes; individuals distressed by unwanted blasphemous thoughts may find relief in counting to 10 backward and forward 100 times fo r each thought. In some cases, individua ls perform rigid or s tereotyped acts accord ing to idiosyncraticaUy elaborated rules w ithout being able to indicate why they are doing them. By de finition , compulSions a re either clearly excessive or are not connected in a realistic way with what Ihey are des igned to neutra li ze or prevent. The mos t common compulsions involve washing and cleaning, counting, checking, requesting o r demanding assurances, repeating actions, and ordering. By definition, adults with Obsessive-Compulsive Disorder have at some p oint recognized that the obsessions or compulsions are excessive or unreasonable. This requirement does not apply to children because they may lack sufficient cognitive aware ness to make this judg ment. H owever, even in adults there is a broad range of
Anxiety Disorders
insight into the reasonableness of the obsessions or compulsions. Some individuals are uncertain about the reasonableness of their obsessions or compulsions, and any given individual's insight may vary across times and situations. For example, the person may recognize a contamina tion compulsion as unreasonable when discussing it in a "safe situation " (e.g., in the therapist's office), but not when fo rced to handle money. At those times when the individual recognizes that the obsessions and compulsions are WU"easonable, he or she may desire or attempt to resist them. \>\'hen attempting to resist a compulsion, the individual may have a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated fa il ure to resist the obsessions or compulsions, the individual may give in to them, no longer experience a desire to resist them, and may incorporate the compulSions into his o r her daily routines. The obsessions o r compuls ions must cause marked distress, be time consuming (take more than 1 hour per d ay), or Significantly interfere with the indiv idual's normal routine, occu pational fun ctioning, or usual socia l activities or relationships with others. Obsessions or compulsions can displace useful and satisfying behavior and can be highly disruptive to o verall functiOning. Because obsessive intrusions can be distracting, they frequently result in inefficient performance of cognitive tasks that require concentration, such as reading or computa tion. In addition, many individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance can become extens ive and can severely restrict general functi oning.
Specifier
With Poor Insight. This specifier can be applied when, for most of the time during the curren t episode, the individual does not recognize that the obsessions or compulsions are excessive or unreasonable.
459
Disorder, with estimates ranging from approximately 35% to 50%. The incidence of lourene's Disorder in Obsessive-Compulsive Disorder is lower, with estimates ranging beh\'een 5% and 7%. Behveen 20% and 30% of individuals with ObsessiveCompulsive Disorder have reported current o r past tics. Associated laboratory findings. No laboratory findings have been identified that are diagnostic of Obsessive-Compulsive Di sorder. However, a variety of laboratory findings have been noted to be abnormal in groups of individuals with ObsessiveCompulsive Disorder relative to conlTol subjects. There is some evidence that some serotonin agonists given acu tely cause increased symptoms in some individuals with the disorder. Lndividuals with the disorder may exhibit increased autonomic activity when confronted in the laboratory with circumstances that trigger an obsession. Physiologica l reactivity decreases after the performance of compulsions. Associated physical examination findings and ge neral medical conditions. Dermatological problems caused by excessive washing w ith wa ter or caustic cleaning agents may be observed.
Anxiety Disorders
Preva lence
Community studies have estimated a life time prevalence of 2.5% and a I -year prevalence of 0.5%- 2.1% in adults. However, methodological problems with the assessment tool used raise the possibility that the true p revalence rates are much lower. Conununity studies of children and adolescen ts have estimated a lifetime preva lence 0 of 10/ -2.3% and a I-year prevalence of 0.7%. Research indicates that prevalence rates of Obsessive-Compulsive Disorder are similar in many differen t cultures around the world.
Course
Although Obsessive-Compulsive Disorder usually begins in adolescence o r early adulthood, it may begin in childhood. Modal age at onset is earlier in males than in females: between ages 6 and 15 years for males and between ages 20 and 29 years for femal es. For the most part, onset is gradual. but acute onset has been noted in some cases. The majority o f individuals have a chronic waxing and waning course, w ith exacerbation of symptoms that may be related to stress. About 15% show progressive deterioration in occupational and social functi oning. About 5% have an episodic course with minimal or no symptoms between episodes.
Familial Pattern
The conco rdance rate for Obsessive-Compulsive Disorder is higher for monozygotic h\'ins than it is for dizygotic hvins. The rate of Obsessive-Compulsive Disord er in firs t-degree biological relatives of individuals w ith Obsessive-Compulsive Disorder and in first-degree biological relatives of individuals w ith Tourette's Disorder is higher than tha t in the general population.
Differential Diagnosis
Obsessive-Compulsive Disorder must be distinguished from Anxi ety Disorder Due to a General Medical Condition . The diagnosis is Anxiety Disorder Due to a General Medical Condition when the obsessions or compulsions are judged to be a d irect physiological consequence of a specific genera l medica l condition (see p . 476). TIus determination is based on h istory, laboratory finding s. or physical examination. A Substance-Ind uced Anxiety Disorder is d istinguished from Obsessive-Compulsive Disorder by the fa ct tha t a substance (i .e., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the obsessions or compulsions (see
p . 479).
Recurrent or intrusive thoug hts, impulses, images, or behaviors may occur in the con text of many other mental d isorders. Obsessive-Compulsive Disorder is not d iagnosed if the content of the thoughts or the acti vities is exclusively related to another mental disorder (e.g., preoccupation with appearance in Body Dysm orphic Disorde r. preoccupation w ith a feared object o r situation.in Specific or Social Phobia, hair plllling in Trichotillomania). An additional diagnosis o f Obsessive-Compulsive Disorder may stilI be warranted if there are obsessions or compulsions whose content is unrelated to the other mental disorder.
461
In a Major Depressive Episode, persistent brooding about potentially unpleasant circumstances or about possible al ternative 'actions is common and is considered a mood -congruent aspect of depression rather than an obsession. For example, a depressed individual who ruminates that he is w orthless would not be considered to ha ve obsessions because such brooding is not ego-d ystonic. Generali zed Anxiety Disorder is characterized by excessive worry, but such worries are distinguished from obsessions by the fact that the person experiences them as excessive concerns about real-life circumstances. For example, an excessive concern that one may lose one's job would constitute a worry, not an obsession. In contrast, the content of obsessions does not typically involve real-life problems, and the obsessions are experienced as inappropriate by the individual (e.g., the intrusive distressing idea that "God" is "dog" spelled backward). If recurrent distressing thoughts are exclusively related to fea rs of haVing, or the id ea that one has, a serious disease based on misinterpretation of bodily symptoms, then Hypochondriasis should be diagnosed instead of Obsessive-Compulsive Disorder. However, if the concern about having an illness is accompanied by rituals such as excessive washing or checking behavior related to concerns about the illness or about spreading it to other people, then an additional diagnosis of ObsessiveCompulsive Disorder may be indicated. If the major concern is about contracting an illness (rather than having an illness) and no rituals are involved, then a Specific Phobia of illness may be the more appropriate diagnosis. The ability of individuals to recognize that the obsessions or compulsions are excessive or unreasonable occurs on a continuum. In some ind ividuals with ObsessiveCompu lsive Disorder, reality testing may be lost, and the obsession may reach delusional proportions (e.g., the belief that one has caused the death of another person by having willed it). In such cases, the presence of psychotic featUres may be indicated by an additional diagnosis of Delusional Disorder or Psychotic Disorder Not Othenvise Specified. The specifier With Poor Insight may be useful in those situations that are on the boundary between obsession and delusion (e.g., an ind ividual whose extreme p reoccupation w ith contamination, although exaggerated, is less intense than in a Delusional Disorder and is justified by the fa ct that germs are indeed ubiquitous). The rumina tive delusional thoughts and bizarre stereotyped behaviors that occur in Schizophrenia are distinguished from obsessions and compulsions by the fac t that they are not ego-dystonic and not subjcct to reality testing. However, some individuals manifest symptoms o f both Obsessive-Compulsive Disorder and Schizophrenia and warrant both diagnoses. Tics (in T ic Disorder) and stereotyped movements (in Stereotypic Movement Disorder) must be distinguished from compulsions. A fic is a sudd en, rapid, recurrent, nonrhytlunic stereoty ped motor movement Or vocalization (e.g., eye blinking, tongue protrusion, throat clearing). A stereotyped movemeJlf is a repetitive, seemingly driven nonfunctional motor behavior (e.g., head banging, body rocking, self-biting). In contrast to a compu lsion, tics and stereotyped movemen ts are typically less complex and are not aimed at neutralizing an obsession. Some individuals man ifest symptoms of both Obsessive-Compulsive Disorder and a Tic Disorder (especiaUy Tourette's Disorder), and both d iagnoses may be warranted. Some activities, such as eating (e.g., Eating Disorders), sexua l behavior (e.g.,
462
Anxiety Disorders
Paraphili as), gambling (e.g., Path ological Gambling), or substance use (e.g., Alcohol Dependence or Abuse), when engaged in excessively, have been referred to as "com-
pulsive." However, these activities are not considered to be compulsions as defined in this manual because the person usually derives pleasure from the activity and may wish to resist it only because of its deleterious consequences.
Although Obsessive-Compulsive Personality Disorder and Obsessive-Compulsive
Di sorder have similar names, the clinical manifestations of these disorders are quite d ifferent. Obsessive-Compulsive Personality D isorder is not characterized by the
presence of obsessions or compulsions and ins tead involves a pe rvasive pattern of preoccupation with orderliness, perfectionism , and control and must begin by early adulthood . If an individual manifests symptoms of both Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder, both diagnoses can be given. Superstition s and repetitive checking beh aviors are commonly encountered in everyday life. A diagnosis of O bsessive-Compulsive Disorder should be considered only if they a re particularly time con suming or resul t in clinically s ignificant impairment or distress.
some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about reallife problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images a re a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, cou nting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviors or mental acts a re aimed at preventing or reduCing distress or preventing some dreaded event or situation; however, these behaviors or menta l acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive 8. At some point during the course of the disorder, the person has recogn ized that the obsessions or compulsions are excessive or unreasonable. Note : Th is does not apply to children.
D. If another Axis I d isorder is present, th e content of t he obsessio ns or compulsio ns is not restricted to it (e.g .. preoccupatio n w ith fo od in the presence of an Eat ing Disorder; hair pulling in t he presence of Trichoti ll omania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in t he presence of a Subst a nce Use Disorder; preoccupatio n wit h having a serio us ill ness in the presence of Hypocho ndriasis; preoccupatio n with sexual urges o r fa ntasies in the presence of a Pa raph ilia; or guilty ruminatio ns in the presence of Majo r De pressive Disorder).
E. The distu rba nce is not due t o the direct physio logical effects of a substance (e.g .. a
if, fo r most of the time during the current e pisode, the perso n does not recognize t hat t he o bsessions and co mpulsions a re excessive o r unreasona ble
309.81
Diagnosti c Features
The essential feature of Posttra uma tic Stress Disorde r is the d e velo pment of characteris tic sympto ms follow ing e xpos w e to an extreme tra umatic s tressor involving direct persona l exp erience of an even t tha t involves a ctual o r th reate ned dea th o r serio us injury, or o ther threa t to one's physical integ rity ; o r w itnessing an even t tha t involves death, injury , o r a thre a t to the phYSical integ rity o f another pe rso n; or le arning a bo ut unexpected or vio len t d ea th, serio us harm, or thre a l of de a th or injury expe rienced by a family member o r o the r close associate (Criterio n AI ). The person's response to the event must involve intense fea r, he lpless ness, o r ho rro r (or in ch ildren, the resp onse mus t invo lve d isorganized or agita ted be hav io r) (Cr iterion A2). The charac teristic sympto m s res ulting fro m the exposw e to the ex trem e tra uma include pers iste nt reexpe riencing of the tra umatic event (Cri te rion B), persis tent avoid ance of s timuli associa ted w ith the trauma and n umbing of gene ra l res ponsiven ess (Crite rio n C), and p ersiste nt symptom s of increa sed arous a l (C riterion D). The fu ll symptom picture must be prese nt fo r m o re than 1 m o nth (Crite rion E), and the distwban ce mus t cause clinica lly sig nifica nt dis tress or impa irm e nt in social, occupa tio nal, o r othe r important area s of functiOning (Criterio n F) . Tra uma tic events that are experi enced directly includ e, but a re not limited to, military co mbat, viole nt persona l assa ult (sexual assault, phys ical attack, rob bery, mugging), being kidnapp ed , being taken hostage, terroris t atta ck, to rture, incarcera tio n as a p risone r of w ar or in a concentration camp, natural o r manmad e d isa sters, severe
Anxiety Disorders
au tomobile accidents, or being d iagnosed w ith a We-threatening illness. For children, sexuaUy traumatic events may include d evelopmentally inappropria te sexual experiences without threa tened or actual v iolence or injury. Witnessed events include, but Me not limited to, observing the serious inju ry or unnatural death of another person due to violent assault, accid ent. war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not li mited to, violent personal assa ult, serious accident, or serious injury experienced by a fam ily member or a close friend; learning about the sudden, unexpected death o f a family member or a close friend; or learning that one's child ha s a Wethreatening disease. The disord er may be especially severe or long lasting when the stressor is of human d esign (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Cri terion 81 ) or recurrent distressing dreams during which the event can be replayed or o them'ise represen ted (Criterion 82). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during w hich components of the event are relived and the person beha ves as tho ugh experiencing the event at that moment (Criterion 83). These episodes, often referred to as " fla shbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological d is tress (Criterion 84) or physiological reactivity (Criterion 85) often occurs when the person is exposed to triggering events that resemble o r symbolize an aspect of the tra umatic event (e.g., anniversaries of the traumatic event; cold , snow y weather or uniformed guards for sun' ivors of dea th camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator). Stimuli associa ted with the trauma are persistently avoided . The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations abou t the traumatic event (Criterion Cl) and to avoid activities, situations, o r people w ho arouse recollections o f it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic even t (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion CS), or o f having markedly reduced ability to feel emotions (especiaUy those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense o f a foreshortened future (e.g., not expecting to have a career, marriage, child ren, or a normal life span) (Criterion C7). The individual has persistent sym p toms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling o r staying asleep tha t may be due to recurrent nightmares during which the traumatic even t is relived (Criterion 01 ), hypen ' igiJance (Criterion 04), and exaggerated startle response (Criterion DS). Some individ uals report irritability o r outbursts of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).
465 \
Specifiers
The foUowing specifiers may be used to specify onset and duration of the symptoms of Posttraumatic Stress Disorder: Acute. This specifier should be used when the duration o f symptoms is less than 3 months. Chronic. This specifier should be used when the symptoms last 3 months or longer. With Delayed Onset. This specifier indicates tha t at least 6 months have passed behveen the traumatic event and the onset of the symptoms.
Anxiety Disorders
In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters, of rescuing others, or of threats to seU or others. Young children usually do not have the sense that they are reliving the past; rather, the reliving of the trauma may occur through repetitive play (e.g., a child who was involved in a serious automobile accident repeatedly reenacts car crashes with toy cars). Because it may be difficult for ch ild ren to report diminished interest in significant activi ties and constriction of affect, these symptoms should be carefully evaluated with reports from parents, teachers. and other observers. In children, the sense of a fo reshortened future may be evidenced b y the belief that life will be too short to include becoming an ad ult. There may also be "omen formation"-that is, be lief in an ability to foresee future untoward events. Children may also exhibit various physical symptoms, such as stomachaches and headaches.
Prevale nce
Community-based studies reveal a lifetime prevalence for Posttraumatic Stress Disorder of approximately 8% of the adult popula tion in the United States. Information is not curren tly available with regard to the general population prevalence in other countries. Studies of at-risk individuals (i.e., groups exposed to specific traumatic incidents) yield variable findin gs, with the highest rates (ranging behveen one-third and more than half of those exposed) found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.
Course
Posttraumatic Stress Disorder can occur at any age, including childhood. Symptoms usually begin within the first 3 months after the trauma, although there may be a d~ lay of months, or even years, before symptoms appea r. Frequently, a person's reac tion 10 a trauma initially meets criteria for Acute Stress Disorder (see p. 469) in the immediate aflennath of the trauma. The symptoms of the disorder ilnd the relative predominance of reexperiencing, avoidance, and hyperarousal symptoms may vary over time. Duration of the symptoms varies, w ith complete recovery occurring within 3 months in approximately half of cases, w ith many o thers having persisting symptoms fo r longer than 12 months afler the trauma. In some cases, the course is characterized by a waxing and waning of symptoms. Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events. The severity, duration, and proximity of an individual's exposure to the trawnatic event are the most important factors affecting the likelihood of developing this disorder. There issome evidence that social supports, famil y history, childhood experiences, personality variables, and preexisting mental disorders may influence the d evelopment of Posttraumatic Stress Disorder. This disorder can develop in individuals without any predisposing conditions. particularly if the stressor is especially extreme.
Familial Pattern
There is evidence of a heritable com ponen t to the transmission of Posttraumatic Stress Disorder. Furthennore, a history of depression in first-d egree relati ves has
309.81
467 \
to developing Postraumatic Stress
Differenti al Diagnosis
In Posttraumatic Stress Disorder, the stressor must be of an_ extreme (i.e., life-threatening) nature. In contrast, in Adjustment Disorder, the stressor can be of any severity. The diagnosis of Adjustment Disorder is appropriate both for situations in which the response to an extreme s tressor does not meet the criteria for Posttraumatic Stress Disorder (or another specific mental disorder) and for situations in which the symptom pattern of Posttraumatic Stress Disorder occurs in response to a stressor that is not extreme (e.g., spouse lea\'ing, being fired ). N ot all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to Posttraumatic Stress Disorder. Symptoms of avoidance, numbing, and increased arousal that are present before exposure to the stressor do not meet criteria for the diagnosis of Posttraumatic Stress Diso rder and require consideration of other diagnoses (e.g., a Mood Disorder or another Anxiety Disorder). Moreover, if the symptom response pattern to the extreme stressor meets criteria for another mental disorder (e.g., Brief Psychotic Disorder, Conversion Disorder, Major Depressive Disorder), these diagnoses should be given ins tead of, or in addition to, Pos ttraumatic Stress Disorder. Acute Stress Disorder is distinguished from Posttrawnatic Stress Disorder because the symptom pattern in Acute Stress Disorder must occur within 4 weeks of the traumatic event and resolve within that 4-week period. If the symptoms persis t for more than 1 month and meet criteria for Posttraumatic Stress Disorder, the diagnosis is changed from Acute Stress Disorder to Posttraumatic Stress Disorder. In Obsessive-Compulsive Disorder, there are recurrent intrusive thoughts, but these are experienced as inappropriate and are not related to an experienced traumatic event. Flashbacks in Posttraumatic Stress Disorder must be distinguished from illus ions, hallucinations, and other perceptual disturbances that may occur in Schizophrenia, other Psychotic Disorders, Mood Disorder With Psychotic Features, a delirium, Substance-Induced Disorders, and Psychotic Disorders Due to a General Medical Condition. Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations playa role.
that involved actual or threatened death or serious injury, or a threat to the physica l integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior
Anxiety Disorders
(2)
(3)
(4) (5)
recurrent and intrusive distressing recollections of the event, including images, thoughts, o r perceptions. Note: In you ng children, repetitive play may occur in which themes or aspects of the trauma are expressed . recurrent dirtressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. acting or feeling as if the traumatic event were recu rring (i ncludes a sense of reliving the experience, illusions, hallucinations, and dissociative flashbac k episodes, including those that occu r on awakening or when intoxicated). Note: In young ch ildre n, trauma-specific reenactment may occur. intense psychological dirtress at exposure to interna l or externa l cues that symbol ize or resem ble a n aspect of the t raumat ic event physio logical reactivity on exposure to internal or externa l cues that symbol ize or rese mble an aspect of the traumatic event
C. Persistent avoidance of rti mu li associated w ith the tra uma and numbing of genera l responsiveness (not present before the trauma), as indicated by three (or more) of the follow ing :
(1) efforts to avoid thoughts, fee lings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that a rouse recollections of the trauma
restricted range of affect (e.g., unable to have loving feelings) (7) sense of a foreshortened future (e.g., does not expect to have a career, mar riage, chi ldren, or a normal life spa n)
(6)
D. Persistent symptoms of increased a rousa l (not present before the trauma), as indicated by two (or more) of the following :
(1) (2) (3) (4) (5) E.
difficulty fall ing or staying asleep irritability o r outbursts of anger difficulty concentrating hypervigilance exaggerated startle response
Duration of the disturbance (symptoms in Criteria B, C, and 0 ) is more than 1 month. tional, or other importa nt areas of fu nct ion ing.
F. The disturbance causes clinically significant distress or impa irment in social, occupa-
Specify if:
Acute: if durat ion of symptoms is less than 3 months Chronic: if duration of symptoms is 3 mont hs or more
Specify if:
308.3
Diagnostic Features
Ac~te
Stress Disorder
The essential feature of Acute Stress Di sorder is the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after exposure to an extreme traumatic stressor (Criterion A). For a discussion of the types of stressors involved, see the description of Posttraumatic Stress Disorder (p. 463). Either while experiencing the traumatic event or after the event, the individual has at least three of the foll owing dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings; derealization; depersonalization; or dissodative amnesia (Criterion B). Following the trauma, the traumatic event is persistently reexperienced (Criterion C), and the individual displays marked avoidance of stimuli tha t may arouse recollections of the trauma (Criterion D) and has marked symptoms of anxiety or increased arousal (Criterion E). The symptoms must cause clinically significant distress, significantly interfere with normal fun ctioning, or impair the individual's ability to pursue necessary tasks (Criterion F). The dis turbance lasts for a minimum of 2 days and a maximum of 4 weeks after the traumatic event (Criterion G); if symptoms persist beyond 4 weeks, the diagnOSiS of Posttraumatic Stress Disorder may be applied. The symptoms are not due to the direct physiological effects of a substance (Le., a drug of abuse, a medication) or a general medical condition, are not better accounted for by Brief Psychotic Disorder, and are not merely an exacerbation of a preexisting mental disorder (Criterion H). As a response to the traumatic event, the individual develops dissociative symptoms. Individua ls w ith Acute Stress Disorder may have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities, and frequently feel gUilty about pursuing usual life tasks. They may experience difficulty concentrating, feel detached from their bodies, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia). In addition, at least one symptom from each of the symptom clusters required foe Posttraumatic Stress Disorder is present. First, the traumatic event is persistently reexperienced (e.g., recurrent recoUections, images, thoughts, dreams, ill usions, fla shback episodes, a sense of reliving the event, or distress on exposure to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided . Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness).
470
led to another's death or to serious injury, survivors may feel guilt about having remained intact or about not providing enough help to others. Individuals with this d isorder often perceive themselves to have greater responsibility for the consequences of the trauma than is warranted. Problems may resu lt from the individual's neglect of basic health and safety needs associated with the aftennath of the trauma.Individuals with this disorder are a t increased risk for the development of Posttraumatic Stress D isorder. Rates of Posttraumatic Stress Disorder of approximately 80"'/0 have been reported for motor vehicle crash slln' ivors and victims of violent crime whose response to the trauma initially met criteria for Acute Stress Disorder. Impulsive and risk-taking behavior may occur after the trauma . Associated physical examination findings and general medical conditions . General medical conditions may occur as a consequence of the trauma (e.g., head injury, burns).
Preva lence
The prevalence of Acu te Stress Disorder in a popula tion exposed to a seriolls traumatic stress depend s on the severity and persistence of the trauma and the degree of exposure to it . The prevalence of Acute Stress Disorder in the general population is not known. In the few available studies, rates ranging from 14% to 33% have been reported in individuals exposed to severe tralUna (i.e., being in a motor vehicle accident, being a bystander at a mass shooting).
Course
Symptoms of Acute Stress Disorder are experienced during or immediately after the trauma, last for at least 2 days, and either resolve within 4 weeks after the conclusion of the traumatic event or the diagnosis is changed . When symptoms persist beyond 1 month, a diagnosis of Pos ttraumatic Stress Disorder may be appropriate if the full criteria for Posttraumatic Stress Disorder are met. The severity, duration, and proximity of an individual's exposure to the traumatic event are the most important factors in determining the likelihood of development of Acute Stress Disorder. There is some evidence that social supports, famil y history, childhood experiences, personality variables, and preexisting mental disorders may influence the development of Acu te Stress Disorder. This disorder can develop in individuals withou t any predisposing conditions, particularly if the stressor is especially extreme.
471
Differential Diagnosis
Some symptomatology follow ing exposure to an extreme stress is ubiquitous a nd often does n ot require any diagnosis . Acute Stress Disorder should only be considered if the symptoms last at leas t 2 days and caus e clinically significant distress or impairment in social, occupational, or other important areas of functioning or impair the indi vidual 's ability to pursue some n ecessa ry task (e.g., obtaining necessary assis tance or mobilizing personal resources by telling family members about the tra umatic experience). Acute Stress Disorder mus t be dis tinguished from a Men tal Disorder Due to a General Medical Condition (e.g ., head trauma) (see p . 181) and from a Substa nceInduced Disorder (e.g., related to Alcohol Intoxication) (see p. 209), which may be common consequences of exposure to an extreme stressor. In some individuals, p sychotic symptoms may occur follow ing an extreme s tressor. In such cases, Brief Psychotic Disorder is d iagnosed instead of Acute Stress Disorder. If a Major Depressive Episode develops after the trauma, a diagnosis of Major Depressive Disorder should be cons idered in addition to a diagnosis of Acute Stress Disorder. A separate diagnosis of Acute Stress Disorder should not be made if the symptoms a re an exacerbati on of a preexisting mental disorder. By definition, a diagnosis of Acute Stress D isorder is appropriate only for symptoms that occur within 1 month of the extreme stressor. Because Posttra um atic Stress Disorder requires more than 1 month of symptoms, this diagnos is cannot be made during this initial I-month period. For individuals with the diagnosis of Acu te Stress Disorder w hose symptoms persis t for longer than 1 month, the diagnosis of Pos ttrauma tic Stress Disorder should be cons idered . For individuals who ha ve an extreme stressor but who develop a symptom pattern that d oes not meet criteria for Acute Stress Disorder, a diagnosis of Adj u stment Disorder should be considered . Malingering must be ruled out in those situations in w hich financial remuneration, benefit eligibility, or forensic determinations pla y a role.
were present:
(1) the person experienced, w itnessed, or was confronted with an event or events
that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or othe rs (2) the person's response involved intense fea r, helplessness, or horror B. Either whi le experiencing or after experi encing the distressing event, the individual has three (or more) of the fol lowing dissociative symptoms:
(1) a subjective sense of numbing, detachment, or absence of emotional respon-
siveness a reduction in awareness of his or her surround ings (e.g., "being in a daze ") derealization depersona lization dissociative amnesia (i .e., inability to recall an important aspect of the trauma)
tiona L or other important areas of functioning or impairs the individual's ability to pu rsue some necessary task, such as obtaining nece ssary assistance or mobi lizing personal resources by t el ling family members about the t raumatic experience. G. The distu rbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
H. The d ist urbance is not due to the di rect physiological effects of a su bstance (e.g., a d rug of abuse, a medication) or a genera l medical condition, is not better account ed fo r by Brief Psychotic Disorder, and is not mere ly an exacerbation of a preexisting Axis I or Axis II disorder.
473 \
a
difficulty controlling the worry, or experience related impairment in social, occupationa l, or other important areas of functioning (Criterion E). The disturbance is nol due to the direct physiological effects of a substance (i.e., a drug o f abuse, a medication, or toxin exposure) or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or Pervasive Developmental Disorder (Criterion F). The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has d ifficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine We circumstances such as possible job responsibilities, finances, the health of family members, mis fortune to their children, or minor matters (such as ho usehold chores, car repairs, or being late for appointments). Children with Generalized Anxiety Disord er tend to worry excessively about their competence or the quality of their performance. During the course of the di sorder, the focus of worry mny shift from one concern to another.
474
Generalized Anxiety Disorder may be overdiagnosed in children. In consid ering this d iagnosis in children, a thorough evaluation for the presence of other childhood Anxiety Disorders should be d one to determine whether the worries may be better expla ined by one of these disorders. Separa tion Anxiety Disorder, Social Phobia, and Obsessive-Compulsive Disord er are often accompa nied by worries that may mimic those described in Generalized Anxiety Disorder. For example, a child with Social Phobia may be concerned about school performance because of fear of humiliation. Worries about illness may also be better explained by Separation Anxiety Disorder or Obsessive-Compulsive Disorder. In clinical settings, the disorder is d iagnosed somewha t mo re frequently in women than in men (about 550/0-60% of those presen ting with the disorder are female). In epidemiological studies, the sex ratio is approxima tely two-thirds female.
Prevalence
In a community sample, the l -year prevalence ra te for Generalized Anxiety Disorder was approximately 3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter of the ind ividuals have Generalized Anxiety Disorder as a presenting or comorbid diagnosis.
Co urse
Many individuals with Generalized Anxiety Disorder report that they have felt anxious and nervous all their lives. Although over half of those presen ting for treatment report onset in childhood or adolescence, onset occurring after age 20 years is not uncommon. The course is chronic but fluc tuating and often worsens during times of stress.
300.02 General ized A nxiety Diso rder (I ncl udes Ove ranxious Disord er of Childhoo d)
475
of heavy coffee consumption would be d iagnosed as Caffeine-Induced Anxiety Disorder, With Generalized Anxiety. When another Axis I disorder is present, an additional d iagnosis of Generalized Anxiety Disorder should be made only when the focu s of the anxiety and worry is unrela ted to the other disorder, th at is, the excessive worry is not restTicted to having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phob ia), being contamina ted (as in Obsessive-Compulsive Disorder), gaining weight (as in Anorexia N ervosa), having a serious illness (as in Hy pochondriasis), ha ving multiple physical co mplaints (as in Somatization Disorder), or to concerns about the weUare of close relations or being away from them or from home (as in Se parati on Anxiety Disorder). For example, U anxiety present in Social Phobia is focused on le upcoming social situations in which the individual mu st perform or be evaluated by others, whereas individuals with Generalized Anxiety Disorder experience anxiety whether or not they are being evaluated . Several features distinguish the excessive w orry of Generalized Anxiety Disorder from the ob sess ional thoug hts of Obsessive-Compulsive Disorder. Obsessiona l thoughts are not simply excessive worries abou t everyday or real-We problems, bu t rather are ego-dystonic intrusions that often take the fo nn o f urges, impulses, and images in addition to though ts. Finally, most obsessions are accompanied by compulsions that reduce the anxiety associated with the obsessions. Anxiety is invariably present in Pos ttraumatic Stress D isorder. Generalized Anxiety Disorder is no t diagnosed if the anxiety occurs exclusively during the course of Posttraumatic Stress Disorder. Anxiety may also be present in Adjus tment Disorder, but this residual category should be used only when the criteria are not met for any other Anxiety Disorder (including Generalized Anxiety Disorder). Moreover, in Adjustment Disorder the anxiety occurs in response to a life stressor and does not persis t for more than 6 months after the termination of the s tressor or its consequences. Generalized anxiety is a common associated feature of M ood Disorders and Psychotic Disorders and should not be diagnosed separately if it occurs exclUSively during the course of these conditions. Several features distinguish Generalized Anxiety Disorder from non p atholog ical anxiety. Firs t, the worries associated with Generalized Anxiety Disorder are difficult to control and typically interfere significa ntly with fWlc tioning, whereas the worries of everyday We are perceived as more controllable and can be put off until later. Second, the worries associated with Generalized Anxiety Disorder are more pervasive, pronOlmced , d is tressing, and of lon ger duration and frequently occur without precipitants. The more life circumstances about which a person worries excessively (finances, children's safety, job performance, car repairs), the more likel y the d iagnosis . Third , everyd ay w orries are much less likely to be accompanied by physical symptoms (e.g., excessive fatigue, restlessness, feeling keyed up or on edge, irritability), althou gh this is less true of children.
476
Anxiety Disorders
C. The anxiety and worry are associated w ith three (or mo re) of the follow ing six symp-
toms (with at least some symptoms present for more days than not for the past
6 months), Note: Only one item is required in chi ldren.
(1) re stlessness or feeling keyed up or on edge
(2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension
(6) sleep disturbance (difficulty fall ing or staying asleep, or restless unsatisfying sleep) O. The focus of the anxiety and worry is not confined to features of an Axis I d isorder, e.g ., the anxiety o r worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Socia l Phobia), being contaminated (as in ObsessiveCompulsive Disorder), being away from home or close re latives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical compla ints (as in Somatization Disorder), or havin g a serious illness (as in Hypochon driasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder. E. The anxiety, worry, o r physical symptoms cause clinically significant distress or impa irment in social, occu pationa l, o r other important areas of fu nctioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, o r a Pervasive Developmental Disorder.
293.84
terion B). The disturbance is not better accounted for by another mental disorder, such as Adjus tment Disorder With Anxiety; in which the s tressor is the general medical condition (Criterion C). The d iagnosis is not made if the anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symptoms must ca use clinically significant dis tress or impainnent in social, occupational, or other important areas of fWlctioning (Criterion E). In determining whether the anxiety symptoms are due to a general medical condition, the clinician mus t first es tablish the presence of a general medical condition. Further, the clinician must establish that the anxiety symptoms are etiologically related to the general medical condition through a physiological mechanis m . A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Although there are no infallible guidelines for determining w hether the relationship beh veen the anxiety symptoms and the general medical condition is etiological, several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and the anxiety symptoms. A second consideration is the presence of feahues that are atypical of a primary Anxiety Disorder (e.g., atypical age at onset or course, or absence of famil y history). Evidence from the literature that s uggests that there can be a direct association beh\'een the general m edical condition in question and the development of anxiety symptoms may provide a useful context in the assessment of a particular situation. in addition, the clinician must also judge that the dis turbance is not better accounted for by a primary Anxiety Disord er, a Subs tanceInduced Anxiety Disorder, or other primary mental disorders (e.g., Adjus tment Disorder). These determinations are explained in greater d etail in the "Mental Disord ers Due to a General Medical Condition " section (p. 181).
Specifiers
The following specifiers can be llsed to indicate which symptom presentation predominates in Anxiety Disorder Due to a General Medical Condition: With Generalized Anxiety. This s pecifier may be used if excessive anxiety or w orry about a number of events or activities predominates in the clinical presentation. With Panic Attacks. This sp ecifier may be used if Panic Attacks (see p . 430) p redominate in the clinical presentation. With Obsessive-Compulsive Symptoms. TIus specifier may be used if obsessions or compulsions predominate in the clinical presentation.
478
Anxiet y Disorders
thyrotoxicosis). See Appendix G fo r a list of ICO-9-CM diagnostic cod es for selected general medical conditions.
Differential Diagnosis
A separa te diagnosis of Anxiety Disorder Due to a General Medical Cond ition is not given if the anxiety disturbance occurs exclusively during the course of a delirium. However, a diagnOSiS of Anxiety Disorder Due to a General Medical Cond ition may be given in addi tion to a diagnosis of dementia if the anxiety is a dire<:t etiological consequence of the pathological process causing the dementia and is a prominent part of the clinical presen tation . U the presentation includes a mix of different types of symptoms (e.g., mood and anxiety), the specific Mental Disorder Due to a Genera] Medical Cond ition depends on which symptoms pred ominate in the clinical picture. If there is evidence of recent or prolonged substance use (includ ing medications wi th psychoactive effe<:ts), withdrawal from a substance, or exposure to a toxin, a Substance-Induced Anxiety Di sorder should be considered. It ma y be useful to obtain a urine or blood drug screen or o ther approp ria te laboratory evaluation. Symptoms tha t occur during or shorlly after (i.e., within 4 weeks of) Substance Intoxication or Withdrawal or after medication use may be especially indicative of a SubstanceInduced Anxiety Disorder, depending on the type, duration, or amolUlt of the substance used . If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Anxiety Disorder Due to a General Medical Cond ition and Substance-Induced Anxiety Disord er) can be given. Anxiety Disorder Due to a General Medical Condition should be distinguished from a pri mary Anxiety Disorder (especially Panic Disorder, Generalized Anxiety Disorder. and Obsessive-Compulsh'e Disorder) and from Adjustment Disorder With Anxiety or Wit~Mixed Anxiety and Depressed Mood (e.g., a maladaptive response to the stress of having a general medical cond ition). In primary men tal disorders, no specific and direct causative physiolOgica l mechanisms associated with a general medical condition can be demonstrated . Late age at onset and the absence of a personal or family history of Anxiety Disorders suggest the need for a thorough assessment to rule oul the diagnosis of Anxiety Disorde r Due to a General Medical Condition. In addition, anxiety symptoms may be an associated feature of anoth er mental disorder (e.g., Schizophrenia, An orexia Nervosa). Anxiety Disorder N ot Othenvi se Specified is d iagnosed if the clinician cannot de-
C. The disturbance is not better accounted for by anoth er ment al disorder (e.g., Adjustment Disorder With Anxiety in which the stressor is a se ri ous general medica l condition). D. The disturbance does not occur exclusively during the cou rse of a del irium. E. The d isturbance causes clin ica lly significant distress or impairment in social, occupat ional, or other important areas of fun ctioning.
Specify if:
With Generalized Anxiety: if excessive anxiety or worry about a number of eve nts or activities predominates in the cli nical presentatio n With Panic Attacks : if Panic Attacks (see p. 432) predom inate in the cl inical presentati on With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation Coding note : Include the name of the general medical cond ition on Axis I, e.g., 293.84 Anxiety Disorder Due t o Pheochromocytoma, With Genera lized Anxiety; also code the general medical condition on Axis 111 (see Appendix G for codes).
4 80
Anxiety Disorders
must not be better accounted for by a mental disorder (e.g., ano ther Anxiety Disorder) that is not subs tance induced (Criterion C). The diagnosis is not made if the anxiety symptoms occur only during the course of a delirium (Criterion D). The symptoms mus t cause clinically signific ant distress or impairment in social, occupationat or other important areas of functioning (Criterion E). This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the anxiety symptoms are in excess of those usually associated w ith the intoxication or withdrawal syndro me and w hen the anxiety symptoms a re s ufficiently severe to warrant independent clinical attention. For a more detailed discussion of Substance-Rela ted Disorders, see p. 191. A Substancelnduced Anxiety Disorder is distinguished from a primary Anxiety Disorder by considering the onset, course, and other fac tors. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings of Dependence, Abuse, intoxication, or withdrawal . Substancelnduced Anxiety Disorders arise only in association w ith intoxication or withdrawal states, whereas primary An xiety Disorders may precede the onset of sub stance use o r occur during times o f sustained abstinence. Because the withdrawal state for some substances (e.g., some benzodiazepines) can be relatively protracted, the onset of the anxiety symptoms can occur up to 4 weeks after cessation of substance use but is usually earlier. Another consideration is the presen ce of features that are atypical of a primary Anxiety Disorder (e.g., aty pica l age at onset or course). For example, the onset of Panic Disorder after age 45 years (which is rare) or the presence o f atypical symptoms during a Panic Attack (e.g., true vertigo; loss of balance, consciousness, or bladder or bowel control; head aches; slurred speech; or amnesia) may suggest a substanceinduced etiology. In contrast, factors suggesting that the anxiety symptoms are better accounted for by a primary Anxiety Disorder include persistence of anxiety symptoms for a substantial period of time (i.e., a month or longer) after the end of Substance Intoxication or acute Withdrawal; the d evelopment o f symptoms that are substantially in excess of wha t would be expected given the type or amount of the substance used o r the duration of use; or a history of prior recurrent primary Anxiety Disorders.
Specifiers
The follOWing specifiers can be used to indicate wh ich symptom presentation predominates: With Ge neralized Anxiety. This specifier may be used if excessive anxiety or worry about 'a number of events or activities predominates in the clinical presentation. With Panic Attacks. This specifier may be used if Panic Attacks (see p. 430) predominate in ~e clinical presentation. With ObsessiveCompulsive Symptoms. This specifier may be used if obsessions or compulsions predominate in the clinical presentation. With Phobic Symptoms. This specifier may be used if phobic symptoms predominate in the clinical presentation.
Substance-Induced Anxiety Disorder The context of the development of the anxiety symptoms may be indicated by using one of the following specifiers: . With Onset During Intoxication. This specifier should be used if criteria for in toxica tion w ith the substance a re met and the symptoms d evelop d uring the in toxication syndrome. With Onset During Withdrawal. This specifier should be used if cri teria for withdrawal from the substance are met and the symptoms develop during, or shortly after, a withdrawal syndrome.
Recording Procedures
The name of the diagnosis of Substance-Ind uced Anxiety Disorder begins with the specific substance (e.g., alcohol, methylphenidate, thyroxine) that is presumed to be causing the anxiety symp toms. nle diagnostic code is selected from the listing of cla sses o f substances provided in the criteria set. For substances that d o not fit into any of the classes (e.g., thyroxine), the code for "Other Substance" shouJd be used . In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code on Axis I (see Appendix G). The name o f the disorder (e.g., Caffeine-Induced Anxiety Disorder) is followed by the specification of the predominant sy mptom presentation and the context in whkh the symptoms developed (e.g., 292.89 Caffeine-Induced Anxiety Disorder, With Panic Attacks, \"Iith Onset During Intoxication). When more than one substance is judged to play a significant role in the development o f anxiety symptoms, each should be listed separately (e.g., 292.89 Cocaine-Induced Anxiety Di sord er, With Generalized Anxiety, With Onset During Intoxication; 291.89 Alcohol-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Withdrawal). U a substance is judged to be the etiological factor, but the specific substance or class of substances is wUmown, the category 292.89 Unknown Substance-Induced Anxiety Disorder should be used.
Specific Substances
Anxiety Disorders can occur in association with intoxication with the following classes of S\lbstances: alcohol; amphetamine and related substances; caffeine; cannabis; cocaine; hallucinogens; inhalants; phencyclidine and related substances; and other or unknown substances. Anxiety Disorders can occur in association w ith withdrawal from the foll owing classes of substa nces: alcoh ol; cocaine; sedatives, h ypnotics, and anxiolytics; and other or unknown substances. Some of the medications reported to evoke anxiety symptoms include anesthetics and analgesiCS, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyrOid preparations, oral contracep tives, antihistamines, anti parkinsonian medications, corticosteroids, antihypertensi\'e and cardiovascular medications, anticonvulsants, li thiwn carbonate, antipsychotic medications, and antidepressant m edications. Heavy metals and toxins (e.g., volatile substances such as gasoline and paint, organophosphate insectiddes, nerve gases, carbon monoxide, carbon dioxide) may also cau se anxiety symptoms.
Differential Diagnosis
Anxiety symptoms commonly occur in Substance Intoxication and Subs tance Withdrawal. The diagnosis o f the substance-specific intoxication or subs tance-specifi c withdrawal w ill us ually su ffice to categorize the symptom presen tation. A diagnosis of Substance-Induced Anxiety Disord er sh ould be mad e ins tead o f a d iagnosis of Subs tance Intoxication or Subs tance Withdrawal only wh en the anxiety symptoms are judged to be in excess of those us ually associated with the intoxication or w ithd rawal synd rome and wh en the anxiety symptoms are s uffi ciently severe to warrant independen t clinical attention . For example, anxiety symptoms are a characteris tic feature of Alcohol W ithdrawal. Alcohol-Induced Anxiety Disorder s hou ld be diagnosed instead o f Alcohol Withdrawal only if the anxiety symp toms are more severe than those usually encountered with Alcohol Withdrawal and are su fficien tly severe to be a separate focus of attention and trea tment. If s ubs tance-induced anxiety sym p toms occur exclusively during the course of a delirium, the an xiety symp toms are considered to be an associated feature of the deliriu m and are not d iagnosed separately. In subs tan ce-induced presentation s that contai n a m ix of different types of symptoms (e.g., mood, psycho tic, and anxiety), the specific typ e of Subs tancelnduced Disord er to be diagnosed depends on w hich type of symptoms p redominates in the clin ical presentation . A Substance-Ind uced Anxiety Disorder is d istinguish ed from a prim ary An xi ety Disorder by the fa ct that a subs tance is judged to be etiologically related to the symptoms (see p. 480). A Subs tance-Induced Anxiety Disorder due to a prescribed treatment for a mental disorder or general medical condition mus t have its onset while the person is receiving the medication (or during withdrawal, if a withdrawal syndrome is associated with the med ication). Once the treatment is d iscontinued, the anxiety symptoms will usually improve markedly or rem it w ithin d ays to several weeks to a mon th (dep end ing on the ha lf-life of the subs tance and the presence of a withdrawal s}' ndrome). If symptoms p ersist beyond 4 weeks, other causes for the anxiety sym p toms should be consid ered . Because individuals with general med ical conditions often take med ications for those cond itions, the clinician mus t consider the possibility that the anxiety symptoms are caused by the physiologica l consequences of the general medical condition rather than the med ication, in which case Anxiety Di sorder Due to a G eneral Medical Condition is d iagnosed. The his tory often provides the p rimary basis for such a judgment. At times, a change in the treatment for the general medical condition (e.g., medication substitution or d iscon tinuation) rna)' be n eeded to determine empirically for that person whether or not the medica tion is the causative agent. If the clinician has ascertained that the disturbance is d ue to both a general medica l cond ition and substance use, both d iagnoses (i.e., Anxiety Disorder Due to a Genera l Medical Condition and Substance-Ind uced Anxiety Disorder) may be given. When there is insufficien t evidence to determin e w hether the anxiety symptoms are due to a subs tance (including a medication) or to a general medical ~onditi o n or are prinlary (i.e., not due to either a substance or a gen eral medical condition), An xiety Disorder Not a thenvi se Specifi ed would be indicated.
Intoxication or Withdrawal (2) medication use is etiologically related to the distu rbance
C. The disturbance is not better accounted for by an Anxiety Disorde r that is not sub
stance induced. Evidence t hat the sympto ms are better accounted for by an Anxiety Disorde r that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute with drawal or severe intoxication o r are substantially in excess of what would be expected given the type o r amount of the substance used or the duration of use; o r there is other evidence sugg esting the existence of an independent nonsubstance-induced Anxiety Disorder (e.g., a history of recurre nt nonsubstance-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. E. The d isturbance causes clinically significant d istress or impairment in social, occupational, or other important areas of functioning. Note: This diagnosis sho uld be made instead of a d iagnosis of Substance Intoxicati on o r
Substance Withd rawa l on ly w hen the anxiety symptoms are in excess of those usually associated with the intoxication o r withdrawal syndro me and when the anxiety symptoms are sufficiently severe to wa rrant independent clin ical attention.
Code [Specific Substance)- Induced Anxiety Disorder
(291.89 Alcohol; 292.89 Amphetamine (or Amphetamine-like Substance); 292 .89 Caffe ine; 292.89 Cannabis; 292 .89 Cocaine; 292.89 Hallucinogen; 292.89 Inha lant; 292.89 Phencycl id ine (or Phencycl idine-like Substance); 292 .89 Sedative, Hypnot ic, o r Anxiolytic; 292 .89 Other [or Unknown) Substance)
Specify if:
With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation With Panic Attacks : if Panic Attacks (see p. 432) predominate in the clinica l presentation With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the cl inical presentation With Phobic Symptoms: if phobic symptoms predominate in the clinical presentation
Specify if (see table on p. 193 for applicability by substance):
With Onset During Intoxication : if the criteria are met for Intoxicat ion with the substance and the symptoms deve lop during the intoxication syndrome With Onset During Withdrawal: if criteria are met fo r Withdrawal from the substance and the symptoms develop during, or shortly after. a withdrawal syndrome
Somatoform Disorders
T he common feature of the Somatoform Disorders is the presence o f physical symptoms that suggest a general medical condition (hence, the term somal%rm) and are not fully explained by a genera l medical condition, by the d irect effects of a substance, or by another mental disorder (e.g., Panic Disorder) . TIle symptoms must social. occupational, or o ther and Malingering, the physical under voluntary control). Somatoform Disorders differ from Psychological Factors Medical Condition in that there is no diagnosable general medical condition . The grouping of these d isorders in a . utility . . to exclude occult ge neral medical conditions or substanceinduced e tiologies for the bodily symptoms) rather than on assumptions regarding shared etiology or mechanism . These disorders are often encountered in general medical settings. The following Somatoform Disorders are included in this section: Somatization Disorder (historically referred to as hysteria or Briq uet's synd rome) is a polysymptomatic disorder that begins before age 30 years, extends over a period of years, and is characterized by a combination of pain, gastroin testinaL sexual, and pseudoneurologicals}'mptoms. Undifferentiated Somatoform Disorder is characterized by unexplained physical complain ts, lasting at least 6 months, that are below the threshold for a diagnosis of Somatization Disorder. Conversion Disorder involves unexplained symptoms or deficits affecting voluntary motor o r sensory fun ction that suggest a neurological or o ther general medical condition. Psychological factors are judged to be associated with the symptoms or deficits. Pain Diso rder is characterized by pain as the pred Ominant focu s of clinica l attention. In addition, psychological fac tors are judged to have an important role in its onset, severity, exacerbation, or maintenance. Hypochondriasis is the preoccupation w ith the fear of having, or the idea that one has, a serious disease based on the person's misinterpreta tion of bodily symptoms or bodily functions. Body Dysmorphic Disorder is the preoccupation w ith an imagined or exaggerated defect in p hysical appearance. Soma to form Disorder Not Otherwise Specified is included for coding d isorders with somatoform symptoms that do not meet the criteria for any of the specific Somatoform Disord ers.
485
So matofo rm Di so rders
300.81
Diagnostic Features
Somatization Disorder
The essential feahue of Somatization Disorder is a pattern of recurring, multiple, clinically significant somatic complaints. A somatic complaint is considered to be c1inicaUy significant if it results in medical treatment (e.g., the taking of medication) or causes significant impairment in social, occupational, or o ther important areas of functioning. The somatic complaints must begin before age 30 years and occur o\'er a period of several years (Criterion A). The multiple somatic complaints cannot be fully explained by any known general medical condition or the direct effects of a substance.1f they occur in the presence of a general medical condition, the physical complaints or resulting social or occupational impainnent are in excess of what would be expected from the history, ph)'sical examination, or laboratory tests (Criterion C) . There must be a history of pain related to at least four different sites (e.g., head, abd om en, back, joints, extremities, chest, rectum) or fun ctions (e.g., menstruation, sexual intercourse, urination ) (Criterion 81). There also must be a history of at lea st two gast.rointestinal symptoms other than pain (Criterion 82). Individuals w ith the disorder frequently describe the presence of nausea and abdominal bloating. Vomiting, diarrhea, and food intoler<lnce are less common . Gastrointestinal complaints often lead to frequ ent X-ray examina tions and can result in abdominal surgery that in retrospect was unnecessary. There must be a histor}' of at least one sexual or reproductive symptom other than pain (Criterion 83). In w omen, this may consist of irregu lar menses, menorrhagia, or vomiting throughout pregnancy. In men, there may be symptoms such as erectile or ejaculatory d ysfunction. Both women and men may be subject to sexual indifference. Finally, there must also be a history of at least one symptom, other than pain, that suggests a neurological cond ition (conversion symptoms such as impaired coordina tion or balance, paralysis o r localized weakness, difficulty swallowing o r lump in throat, aphonia, urinary retention, hallucinations, loss of to uch or pain sensation, double vision, blindness, d eafness, or seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) (Criterion 84). The symptoms in each of the groups have been listed in the approxima te order of their reported frequency. Finally, the unexpla ined symptoms in Somatization Disorder are not in tentionally feigned or produced (as in Factitious Di sorder o r Malingering) (Criterion D).
300.81
Somatization Disord e r
man and may be the reason for being seen in mental health settings. There may be impulsive and antisocial behavior, su icide threats and attempts, and mar ital discord. The lives of these individuals, particula rly th ose with associated Personality Disorders, are o ften as chaotic and complicated as their medical histo ries. Freq uent use of medication s may lead to side effects and Substance-Related Disord ers. These individuals comm only lmdergo numerous medica l examinations, diagnostic p rocedures, surgeries, and hosp italizations, wh ich expose the person to an increased risk of morbidity associated w ith these procedu res. Major Dep ressive Disorder, Panic Disord er, and Substance-Related Disorders are frequently associated with Somatization Disorder. H istrionic, Borderline, and Antisocial Personality Disorders are the most frequently associated Personality Disorders. Associated laboratory findings. Laboratory test results a re remarkable for the absence of fi ndings to support the subjective complaints. Associated physical examination findings and general medical conditions. Physical examination is remarkable fo r the absence of objective find ings to fully explain the many subjective complaints of individ uals with Soma tization Disorder. These individuals m ay be diagnosed w ith so-called fun ctional d isorders (e.g., irritable bowel syndrome). However, because these syndromes are as yet without est,lbIished objective signs or specific laboratory findings, their symptoms may count toward a d iagnosis o f Somati zation Disorder. Some ind iv iduals have objective findings and an associated genera l medica l condition that d oes not fuJl y exp lain the complaints. For exam ple, individ uals w ith hypothyroidism may present with multiple complaints and a significant nu mber of objective findin gs, but the disease would nol expla in such a long history of numerous d iverse complain ts.
Preval ence
Studies have reported widely variable Wetime prevalence rates o f Soma ti zation Disorder, ranging from 0.2% to 2% among women and less than 0.2% in men. Di ffe rences
4 88
Somatoform Disorders
in rates may depend on w hether the interviewer is a physician, on the method of assessment, and on the demographic variables in the samples studied. When nonphysician interviewers are used, Somatization Disord e r is much less frequ ently diagnosed .
Course
Somatization Disorder is a ch ronic but fluctuating d isorder tha t rarely remits com-
pletely. A year seldom passes without the individual's seeking some medical attention prompted by unexplained somatic complaints. Diagnostic cri teria are typicaUy met before age 25 years, but initial symptoms aTe often present by adolescence. Menstrual difficulties may be one of the earliest symptoms in women. Sexual symptoms
are o ften associated with marital discord.
300.81
Somatization Disorder
It can be very difficult to distinguish between Anxiety Disorders and Somatization Disorder. In Panic Diso rder, multiple somatic symptoms are also present, but these occur primarily during Panic Attacks. However, Panic Disorder may coexist with S0matization Disorder; when the somatic symptoms occur at times other than during Panic Attacks, both diagnoses may be made. Individuals with Generalized Anxiety Disorder may have a multitude of physical complaints associated with their generalized anxiety, but the focus of the anxiety and worry is not limited to the physical complaints. Ind ividuals with Mood Disorders, particularly Depressive Disorders, may present with somatic complaints, most commonly headache, gastrointestinal disturbances, or unexplained pain. Individuals w ith Somatization Disorder have physical complaints recu rrently throughout most of their Li\'es, regardless of their current mood state, whereas physica l complaints in Depressive Disorders are limited to episodes of depressed mood. lndividuals with Somatization Disorder also often present with depressive complaints. If criteria are met for both Somatization Disorder and a Mood Disorder, both may be diagnosed . By definition, all ind ividuals with Somatization Disorder have a history of pain symptoms, sexual symptoms, and conversion or dissociative symptoms. Therefore, if these symptoms occur exclusively during the course of Somatization Disorder, there should not be an additional diagnosis of Pa in Disorder Associated Wi th Psychological Factors, a Sexual Dysfunction, Conversion Disorder, or a Dissociative Disorder. Hypochondriasis is not to be d iagnosed if preoccupation with fears of having a serious illness occurs exclusively during the course of Somatization Disorder. The criteria for Soma tiza tion Disorder in this manual are slightly m ore restrictive than the original criteria for Briquet's syndrome. Somatoform presentations tha t d o not meet criteria for Somatiza tion Disorder should be classified as Undifferentiated Somaloform Disorder if the duration of the syndrome is 6 months o r longer, or Somatoform Disorder Not Othenyise Speci fied for present" tions o f shorter duration. In Factiti ous Diso rder With Predominantly Physical Signs and Symptoms and Malingering, somatic symptoms may be intentionally prod uced to assume the sick role or for gain, respectively. Symptoms that are intentionally produced should not count toward a diagnosis of Somatization Disorder. However, the presence o f some factitious or malingered symptoms, mixed with other nonintentional symptoms, is not uncommon . In such mixed cases, both Somatization Disorder and a Factitious Disorder or Malingering should be di agnosed.
490
Somatoform Disorders
functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during
menstruation, during sexual intercourse, o r during urinatio n) (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms othe r than pain (e.g., nausea, bloating, vomiting other than during pregnancy, d iarrhea, or intolerance of several different foods) (3) one sexual symptom: a history of at least one sexual or reproductive symptom othe r tha n pa in (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstr ual bleeding, vomiting throughout pregnancy) (4) one pseudoneurological symptom: a history of at least o ne symptom or deficit suggesting a neurological cond it ion not limited to pain (conversion symptoms such as impaired coordination o r balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retentio n, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting )
C. Either (1) or (2):
(1 ) after appropriate investigati o n, each of the sympt o ms in Criterion B cannot be
fully explained by a known general medical condit ion o r the direct effects of a substance (e.g., a d rug of abuse, a medication) (2) when there is a re lated general medical condition, the physica l co mplaints o r result ing social o r occupational impairment a re in excess of what would be expected fro m the history, physical examination, or laboratory findings
D. The symptoms are not intentionally produced or fe igned (as in Factitious Disorder or
Ma ling ering).
3 00.82
300.82
4 91
examination, or laboratory findings (Criterion B). The symptoms m ust cause clinica lly significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The diagnosis is not made when the symptoms are beNer accounted for by another mental disorder (e.g., another Somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder) (Criterion E). The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering) (Criterion F). This is a resid ual category for those persistent somatoform p resentations that do not meet the full cri teria for one of the specific Somatoform Disorders (e.g., Somatization Disorder). Particular care must be exercised to ensu re the presentation does no t meet the criteria for Somatization Disorder, because individuals with that d isorder typically are inconsistent historians (i.e., reporting insufficient somatic sym ptomatology to meet the criteria at one assessment, but enough symptoms to meet the full criteria at another evaluation). Symptoms that may be seen include the examples listed for Somatization Disorder. There rna}' be a single circumscribed symptom, such as nausea, or, more commonly, multiple physical symptoms. The chronic unexp lained physical complaints often lead to medical consultation, typ ically with a primary care physician.
Course
11le course of individual unexplained physical complaints is unpredictable. The eventual diagnosis o f a genera l med ical condition or another menta l d isorder is frequent.
Differential Diagnosis
Also refer to the Differential Diagnosis section for Somatization Disorder (see p. 488). Undifferentiated Soma tofonn Disorder is differentia ted from Somatization Di sord er by the requiremen t in Somatization Disorder of a m ultiplicity of sym ptoms of severa l years' duration and an onset before age 30 years. If the physical complaints have persisted for less than 6 m onths, a d iagnosis of Somatofonn Diso rd er Not Othen vise Specified should be made. Undifferentiated Somatoform Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder. Other men tal disorders that frequentl y include unexplained physical complaints are Ma jor De-
Soma toform Di so rders pressive Disorder, Anxie ty Disorders, and Adjustment Disorder. in contrast to Undifferentiated Somatoform Disorder, the physical symptoms of Factitio us Disorders and Malingering are intentionally produced or feigned. In Factitious Disorder, the motiva tion is to assume the sick role and to obtain medical evaluation and treatment, whereas in Malingering, more external incentives are apparent, such as finanaal compensa tion, avoidance of duty, evasion of criminal prosecution, or obtaining drugs.
known general medical condition or the direct effects of a substa nce (e.g., a drug of abuse, a medication) (2) when there is a related genera l medical condition, the physica l compla ints or reo suiting social or occupational impairment is in excess of what would be expected from the hist ory, physical examination, or laboratory findings
C. The symptoms cause clinically significant distress or impairment in social, occupation -
al, o r other important areas of functioning . D. The duration of the disturbance is at least 6 months. E. The disturbance is not better accounted fo r by another mental disorder (e.g., another Somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disord er, Sleep Disorder, or Psychotic Disorder). F. The symptom is not intentionally produced or fe igned (as in Factitio us Disorder or Malingering) .
300.11
Diagnostic Features
Conversion Disorder
The essential feature of Conversion Disorder is the presence of symptoms or deficits affecting voluntary m otor or sensory function that suggest a neurological or other general medical condition (Criterion A). Psychologica l fa ctors are judged to be associated w ith the symptom or deficit, a judgment based on the observation that the in itiatio n or exacerbation of the symptom or deficit is preceded by conflicts or other stressors (Criterion B). The symptoms are not.intentionally produced o r feigned, as in Factitious Disorder or Ma lingering (Criterion C). Conversion Disorder is not diagnosed if the symptoms or deficits are full y explained by a neurological or o ther general medical condition, by the direct effects of a substance, or as a culturally
300.11
Conversion Disord e r
493
sanctioned behavior or exp erience (Criterion D). The problem mus t be clinically significant as evidenced by marked distress; impairment in socia l, occupational, or other important areas of functioning; or the fact that it warrants med ical evaluation (Criterion E). Conversion Disord er is not diagnosed if symptoms are limited to pai n or sexual dysfunction, occur exclusively during the course of Somatiza tion Disorder, or are better accounted for by another mental disord er (Criterion F). Conversion symptoms are related. to voluntary motor or sensory fu nctioning and are thus referred to as "p seudoneurological " Motor symptoms or d eficits include impaired coordination or balance, paralysis or localized weakness, aphonia, difficulty swallowing or a sensation of a lump in the throat, and urinary retention. Sensory s)'mptoms or d eficits include loss o f touch or pain sensation, double vision, blindness, deafness, and hallucinations. Symptoms may also include seizures or convulsions. The more medically n aive the person, the more implau sible are the presenting symptoms. More sophis ticated. p ersons tend to have more subtle symptoms and deficits that may c1osel)' simulate neurological or other general medical condHions. A diagnosis of Con version Disorder should be made only after a thorough medical investigation has been performed to rule out an etiological neurologica l or genera l medical condition . Because a general medical etiology for many cases of apparent Conversion Disorder can take years to become evident, the diagnosis should be reeva luated periodically. In early studies, general medical etiologies were later found in from one-quarter to one-half of persons initially diagnosed with conversion symptoms. In more recent s tudies, misdiagnosis is less evident, perhaps reflecting increased awareness of the d isorder, as well as improved knowledge and d iagnos tic techniques. A h istory of other unexplained somatic (es peci ally conversion) or dissociative symptoms signifies a greater likelihood that an apparent conversion symptom is not due to a general medical condition, es pecially if criteria for Somatiza tion Disorder have been met in the past. Conversion symptoms typicall)' do not conform to known anatomical pathways and physiological mechanisms, but ins tead follow the individual's concephJaIization of a cond ition. A "paralysis" may involve inability to p erform a particular movement or to move an entire body p art, rather than a d efi cit corresp onding to p atterns of motor innervation. Conversion symptoms are o ft en inconsistent. A "paralyzed " extremity will be moved inadvertently while dressing or when attention is d irected elsewhere. If p laced above the head and released, a "para lyzed " arm will briefly retain its position, then fall to the side, rather than striking the head. Unacknowled ged strength in antagonistic muscles, nonnal muscle tone, and intact refl exes may be demonstrated. An electromyogram will be normal. Difficulty swallowing will be equal with liquid s and solids. Conversion "anesthesia " of a foot or a hand may follow a so-ca lled s tocking-g love dis tribution with wliform (no proximal to dis tal g radient) loss of all sensory modalities (Le., touch, temperature, and pain) sharply demarcated at an anatomical landmark rather than according to derma tomes. A conversion "seizure" w ill vary from convulsion to convulsion, and paroxysmal activity will not be evident on an EEG. Even when fo llowin g s uch guidelines carefully, caution must be exercised . Knowledge of ana tomical and physiological mechanis ms is incomplete, and available methods of objective assessment have limitations. A broad range of neurolog ical conditions may be misdiagnosed as Conversion Disorder. Prominent among them
are multiple sclerosis, myasthenia gravis, and idiopathic or substance-induced d ystonias. However, the presence of a neurologica l condition d oes not p reclude a diagnosis of Conversion Disorder. As many as one-third of individuals with conversion symptoms have a current or prior neurological condition. Conversion Disorder may be diagnosed in the presence of a neurological or other general medical condition if the symptoms are not fully explained given the nature and severity of the neurological or other general medical condition. Traditionally, the term cOl/version derived from the h ypothesis that the individual's somatic symptom represents a symbolic resolution of an unconscious psychological conflict, reducing anxiety and serving to keep the conflict out of awareness ("p rimary gain" ). The individual might also derive "secondary gain" from the conversion symptom-that is, external benefits are obtained o r noxious duties or responsibilities are evaded. Although the OSM-fV criteria set for Conversion Disorder does not necessarily imply that the symptoms involve such constructs, it does require that psychological factors be associated w ith their onset or exacerbation. Because psychological fac tors are so ubiquitously present in relation to general medical conditions, it can be d ifficult to establish whether a specific psychological fac tor is etiologically related to the symptom or defi cit. However, a close temporal relationship between a conflict or stressor and the initiation or exacerbation of a symptom may be helpful in this determination, especially if the person has developed conversion symptom s under similar circumstances in the past. Although the indi\' idual may derive secondary gain from the conversion symptom, u nlike in Malingering o r Facti tious Disorder the symptoms are not inten tionally p roduced to obtain the benefits. The determination that a symptom is not in tentionally produced or feigned can also be difficult . Generally, it must be inferred from a careful evaluation of the context in which the symptom develops, especially rela tive to potential external rewards or the assumption of the sick ro le. Supplementing the person's self-report w ith additional sources of information (e.g., from associates or record s) may be helpful. Conversion Disorder is not diagnosed if a symptom is full y expla ined as a cul turaUy sanctioned behavior or experience. For example, "visions" or "spells" that occur as part of religious rituals in w hich such behaviors are encouraged and expected would not justify a diagnosis of Conversion Disorder unless the symptom exceeded wha l is contextually expected and caused undue distress or impairment. In "epidemic hysteria," shared symptoms develop in a circumscribed group of people following "exposure" to a common precipitant. A diagnosis of Conversion Diso rder should be made only if the individual experiences clinically significant distress or impairment.
Subtypes
The following subtypes are noted based on the nature of the presenting symptom or deficit : With Motor Symptom or Deficit. Thi s subtype includes such symptoms as impaired coordination or balance, paralysis or localized weakness, difficult)' swallowing or "lump in throa!," aphonia, and u rinary reten tion. With Sensory Symptom or Deficit. This subtype includes such symptoms
300. 11 Conversion Disorder as loss of touch or pain sensation, d ouble vision, blindness, deafness, and hallucinations. With Seizures or Convulsions. This subtype includes seizures or convulsions with voluntary motor or sensory components. With Mixed Presentation. This subtype is used if symptoms o f more than one category are evident.
Somatoform Disorders development. Falling d own with loss or alteration of consciousness is a feature of a variety of culture-specific syndromes. The form of conversion symptoms reflects local cultura l id eas about acceptable and credible ways to express distress. Changes resembling conversion symptoms (as well as d issociative symptoms) are common aspects of certain culturally sanctioned religious and healing rituals. The clinician must assess w hether such symptoms are fully explained in the particular social context, and whether they result in dinically significant distress, disability, or role impairment. Conversion symptoms in children under age 10 years are usually limited to gait problems or seizures. Con version Disorder appears to be more frequent in women than in men, w ith reported ra tios varying from 2:1 to 10:1. Especially in women, symptoms are much mo re common on the left than on the right side of the body. Women (rarely men) presenting w ith con version symptoms may later mani fes t the full picture of Somatization Disorder. In men, there is an association between Conversion Disorder and Antisocial Personali ty Disorder. In addition, Conversion Disorder in men is often seen in the context of industrial accidents or the military.
Prevalence
Reported rates of Conversion Disorder have varied widely, ranging from 11/ 100,000 to 500/ 100,000 in general population samples. It has been reported in up to 3% of outpatient referrals to mental hea lth clinics. Studies of general medical/surgical inpatients have identified conversion symptom rates ranging between 1% and 14%.
Co urse
The onset of Conversion Disorder is generally from late childhood to early adulthood, rarely before age 10 years or after age 35 years, but onset as late as the ninth decade o f life has been reported. Wh en an apparent Conversion Disorder first develops in middle or old age, the probability of an occult neurological or other general medical condition is high . The onset of Conversion Disord er is generally acute, b ut gradually increasing symptomato logy may also occur. Typically, individu~ conversion symptoms are of short duration . In individuals hospitalized with conversion symptoms, symptoms will remit within 2 weeks in most cases. Recurrence is common, occurring in from one-fifth to one-quarter of individuals within 1 year, with a single recurrence predicting future episodes. Factors that are associa ted with good p rognosis include acute onset, presence of clearly identifiable stress at the time of onset, a short in terval between onset and the institution of treatment, and aboveaverage intelligence. Symptoms of paralysis, aphonia, and blindness are associated with a good prognosis, whereas tremor and seizures are not.
Famili al Pattern
Limited data suggest that conversion symptoms are more frequent in relatives of ind ividuals with Conversion Disorder. Increased risk of Conversion Disorder in monozygotic twin pairs but not in dizygotic twin pairs has been reported.
300. 11
Differential Diagnosis
The major diagnostic concern in eva luating potential conversion symptoms is the exclusion of occult n eurolog ical or oth er general m edical condi tions and substance (including medication l-indu ced etiologies. Appropriate eva luation of potential general medical conditions (e.g., multiple sclerosis, myas thenia gravis) should include careful review of the current presentation, the overall medical history, neurological and general physical examinations, and appropriate laboratory studies, including investigation for use of alcohol and other substances. Pain D isorder or a Sexual Dysfun ction is diagnosed instead of Conversion Disorder if the symptoms are lin,ited to pain or to sexual dysfunction, respectively. An add itional diagnosis of Conversion ' Disorder should not be made if conversion symptoms occur excl usively during the course of Som atizati on Disorder. Conversion Disorder is not diagnosed if symptoms are better accounted for by anoth er m en tal disord er (e.g., catatonic symptoms or somatic delusions in Schizop hreni a or other Psychotic Disorders or Mood Disorder or difficulty swallowing during a Pan ic Attack). In Hypoch ond riasis, the individual is preoccupied with the "serious disease" underlying the pseudoneurological symptoms, whereas in Conversion Disorder the focus is on the presenting symptom and there may be /" belle indifference. In Body Dysmorp h ic Disorder, the emphasis is on a preoccupation w ith an imagined or slight defect in appearance, rather than a change in volwl lary molor or sensory function. Conversion Disorder shares features with Di ssociative Di sorders. Both disorders involve symptoms that suggest neurological d ysfun ction and may also have shared antecedents. Ifboth conversion an d dissociative symptoms occur in the same individ ual (which is common), both diagnoses should be made. It is controversial whether hallucinations ("pseudohallucina tions") can be considered as the presenting symptom of Conversion Disorder. As distinguished from h allucina tions th at occur in the con text of a Psychotic Disorder (e.g., Sch izophrenia or another Psychotic Disorder, a Psychotic Disorder Due to a General Medical Condition, a Substance-Related Disorder, or a Mood Disorder '''lith Psycho tic Features), hallucinations in Conversion Disorder genera lly occur w ith intact insight in the absence of other psychotic symptoms, often involve more than one sensory modality (e.g., a hallucination involving visual, auditory, and tactile components), and often have a naive, fa ntastic, or childi sh content. They are often psychologically meaningful and tend to be described by the individual as an interesting story. Symptoms of Factitio us D isorders and Malingering are intentionally p roduced or feigned . In Facti tious Disorder, the motivation is to assume Ihe sick role and 10 obtain medica l evaluation and treatment, whereas more obvious goals such as financia l compensation, avoidance of duty, e\'asion of criminal prosecution, or obtaining d rugs are appa rent in Malingering. Such goals may resemble "secondary gain" in conversion symptoms, with the distinguishing feature of conversion symptoms being the lack of conscious intent in the production of the symptom.
order or Malingering). D. Th e symptom or deficit can not, after appropriate investigation, be fully explained by a gene ral medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinica lly significant distress or impairment in social, occupational, or other important areas of function ing or warrants medical eva luation . F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, a nd is not better accounted for by another mental disorder.
Specify type of symptom or deficit:
Motor Symptom or Deficit Sensory Symptom or Deficit Seizures or Convulsions Mixed Presentation
Pain Disorder
Diag nostic Feat ures
The essential feature of Pain Disorder is pain that is the predomin ant focu s of the clinical presentation and is of s ufficient severity to warrant clinical attention (Criterion A). The pain causes significant distress or impairment in social, occupational, o r other important areas of functioning (Criterion B). Psychologica l factors are judged to pia)' a significant role in the onset. severity, exacerbation, or maintenance of the pain (Criterion C). The pain is not intentionally produced or feigned as in Factitious Disorder or Malingering (Criterion D). Pain Disorder is not d iagnosed if the pain is better accounted for by a Mood, Anxiety, or Psychotic Disorder, or if the pain presentation meets criteria for Dyspareunia (Criterion E). Examples of impairment resulting from the p ain include inability to work or attend school, frequent use of the hea lth care system, the pain becoming a major focus of the individual's life, substantial use of medications, and relational problems s uch as marital discord and disruption of the family's normal lifestyle. The psychological fa ctors involved may consist of another
Pain Diso rder
Axis I or Axis U disorde r (which would also be djagnosed) o r may be of a nature tha i does not reach the threshold for such a disorder (e.g., reactions to psychosocial stressars).
307.80 Pain Di sorder Associated With Psychological Factors. This subtype is used when psychological factors are judged to have the majo r role in the onset, severity. exacerbation, or maintenance of the pain. In this subty pe, general medica l conditions play either no role or a minimal role in the o nset or m aintenance of the pain. This s ubtype is not diagnosed if criteria for Somatization Disorde r are met. 307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition. This subtype is used when both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The ana tomical site of the pain or associated general medical condition is coded on Axis III (see "Recording Procedures"). Pain Disorder Associated With a General Medi cal Condition. Thissubtype of Pain Disorder is /lot considered a mental disorder a/ld is coded all At is III. It is listed in this section to facilitate differential diagnosis. The pain results h om a general medica l condition, and psychological facto rs are judged to play either no role o r a minimal role in the onset or maintenance of the pain. The lCD-9-CM code fo r this subtype is selected based on the location of the pain or the associated general medical condition if this has been established (see " Recording Proced ures"). For Pain Disorder Associated With Psychological Facto rs and Pain Disorder Associa ted With Both Psychological Factors and a General Med ical Condition, the foll owing specifiers may be noted to indicate the duration of the pain: Acute. This specifi er is used if the duration o f the pain is less than 6 months. Chronic. This Specifier is used if the duration of the pain is 6 months or longer.
1 500
location of the pain if the lUlderlying general medical condi tion is not yet clearly established- for example, low back (724.2), sciatic (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.50), joint (719.40), bone (733.90), abdominal (789.0), breast (611.71), renal (788.0), ear (388.70), eye (379.91), throat (784.1), tooth (525.9), and urinary (788.0).
various aspects of daily life. Unemployment, disability, and famil y problems are frequently encountered among individuals with chronic forms of Pain Disorder. Iatrogenic Opioid Dependence or Abuse and Benzodiazepine Dependence or Abuse may d evelop. A history of Substance Dependence or Abuse, whether with an illicit d rug or a p rescribed medica tion, increases the risk for the developmen t of Dependence or Abuse on a con tro lled substance prescribed for pain m anagemen t. However, even individuals w ithout any history of Substance Dependence or Abuse are at some risk for d eveloping these problems. As many as a quarter of individuals prescribed op ioids for treatmen t of ch ronic pain may develop Abuse or Dependence. The risk of iatrogenic Substance Dependence can be minimized by ensuring that the individua l with pain has had an appropriate evaluation to rule ou t the possibility of a treatable underlying etiology fo r the pain; tha t if other m ental disorde rs are p resent, they are appropriately treated; and that medications are prescribed by a single physician rather than having the indiv idual obtaining them from mu ltiple sou rces. Substance Dependence or Abuse (mostly with alcohol) may complicate the lifetime illness course of Pain Disorder in up to a quarter of indiv iduals with ch ronic pain. Individuals whose pain is associated with severe d epression and those whose pain is related to a terminal illness, most notably ca ncer, appear to be at increased risk for s uicide. Individuals w ith recurrent acu te or chronic pain are sometimes convinced that there is a h ealth professional somewhere who has the "cure" for the pain. They may spend a considerable am ount of time and money seeking an unattainable goal. Health care professionals may unwittingly playa role in fostering this behavior. Pain may lead to inactivity and social isolation, which in tum can lead to additional psycho logical problem s (e.g., depression) and a reduction in physical endurance tha t res ults in fatigue and additional pain. Pain Disord er appea rs to be associa ted with other mental disorders, esp ecially Mood and Anxiety Diso rders. Chronic pain appears to be most frequen tly associa ted with Depressive and Anxiety Disorders, whereas acute pain appears to be mo re commonly associated with Anxiety Disorders. The associated mental disorders may p recede the Pain Disorder (and pOSSibly predispose the individual to it), co-occur with it, or result from it. Both the acute and chronic forms of Pain Disorder are freq uen tly associa ted with various sleep p roblems. Common sleep symptoms in individuals w ith chronic pain include delayed sleep onset, frequent awakenings, nonrestorative sleep, and decreased sleep time. Sleep Disorders such as obstructive sleep apnea and nocturnal myoclonus occur at higher rales among individuals w ith chronic pam than in the general population.
Associated laboratory findings . In Pain Disorder Associated With Both Psychological Factors and a Gen eral Medica l Condition, appropria te laboratory testing may
Pain Disorder reveal pathology that is associated with the pain (e.g., finding of a herniated lumbar disc on a magnetic resonance imasY'g (1-00) scan in an individual with radicu lar lowback pain). However, general medical conditions may also be present in the absence of objective findings. Conversely, the presence of such findings may be coincidental to the pain. ln Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, the physical examination may reveal pathology that is associated with the pain. Pain Disorder can be associated with many general medical conditions. Among the most common general medical conditions associated with pain are various musculoskeletal cond itions (e.g., disc herniation, osteoporosis, osteoarthritis or rheumatoid arthritis, myofascial syndromes), neuropathies (e.g., d iabetic neuropathies, postherpetic neuralgia), and ma lignancies (e.g., metastatic lesions in bone, tumor infiltration of nerves) . Attempts to treat the pain may lead to additional problems, some of w hich can cause more pain (e.g., use of nonsteroidal anti-inflammatory drugs resulting in gastrOintestinal distress, overuse of acetaminophen resulting in hepatic d isease, surgery resulting in adhesions).
Associate d phys ical examination f indings and general medical conditions.
Preva le nce
Pain that causes significant distress o r impairment in fun ctioning is widespread . For example, it is estimated that, in any given year, 100/0-15% of adults in the United States have some form of work disability due to back pain (on ly some of whom have Pain Disorder). However, the prevalence of Pain Disorder is unclear. Pain Disorder Associated With Both Psychological Factors and a General Medical Condition appears to be relatively common in certain clinical settings, particular those in which pain is a significant problem (e.g., pain clinics, psychiatric consultation services in a general medical hospital). Pain Disorder Associated With Psychological Factors appears to be much less common.
Co urse
Most acute pain resolves in relatively short periods of time. There is a wide range of variability in the onset of chronic pain, although it appears that the longer acute pain is presen t, the more likely it is' to become chronic and persistent. In most cases, the pain has persis ted for many years by the time the individual comes to the attention of
/ 502
Somatoform Disorders
the mental health profession. important factors that appear to influence recovery from Pain Disorder are the indiv idua l's acknowledgmen t of pain; giving up lUlproductive efforts to control pain; participation in regula rly scheduled activities (e.g., work) d espite the pain; degree of pain reduction; recognition and treatment of comOTbid mental disorde rs; psychological adaptation to chronic illness; a nd not allowing the pain to become the detennining factor in his or her lifestyle. Individuals with
greater numbers of painful body areas and higher numbers of genera l medical symptoms other than pain have a poorer prognosis.
Differential Diagnosis
Pain symptoms are included in the diagnostic criteria for Somatization Disorder. If the pain associated with psychological factors occurs exclusively during the course of Somatization Disorder, an additional diagnosis of Pain Disorder Associated \'\' ith Psychological Factors is not made. Similarly, if the pain presenta tion meets criteria for Dyspareunia (i.e., pain associated with sexual intercourse), an additiona l d iagnosis of Pain Disorder is not given. Pain complaints may be p rominent in individuals with Conversion Disorder, but by definition, Conversion Disorder is not limited to pain symptoms. Pa in symptoms are common associated features of other mental disor ders (e.g., Depressive Disorders, Anxiety Disorders, Psychotic Disorders). An additional diagnosis of Pain Disorder should be considered only if the pain is an independent focus of ciinkal attention, leads to clinically signi fi cant distress or impairment, and is in excess of that usually associa ted w ith the other mental disorder. Pain symptoms may be intentionally produced or feigned in Factitious Disorder or Malingering. In Factitious Disorder, the motivation is to assume the sick role and to obtain medical evaluation and treatment, whereas more obvious goals such as fi nancial compensation, avoidance of duties related to m ilitary service or incarceration, evasion of criminal prosecution, o r obtaining drugs are apparent in Malingering.
Relationship to the Taxonomy Proposed by The International Association for the Study of Pain
The Subcomm ittee on Taxonomy of The International Association for the Study of Pain proposed a fi ve-axis system for categorizing chrornc pain according to anatomical region, Il) organ system, temporal characteristics of pain and pattern of occurrence, TV) patient's statement of intensity and time since onset of pain, and V) etiology. This five-axis system focuses primarily on the physical manifestations of pain. It provides for comments on psychological fac tors on both the second axis where the involvement of a mental disorder can be coded and the fift h axis where possible etiologies include "psychophysiological" and "psychological. "
un
Pa in Disorder
503 \
,
Pain in one or more anatomical sites is the predomin ant focus of the clinical presentat ion and is of sufficient severity to wa rrant clinical attention.
B. The pain causes cl in ica lly significan t distress or impairment in socia l, occupational, or other important areas of function ing.
C. Psychological facto rs a re judged to have an important role in the onset, severity, ex-
acerbation, or ma intenance of the pain. D. The symptom or deficit is not intenti ona lly produced o r feigned (as in Factit ious Disorder o r Mal ingering).
E". The pain is not better accounted fo r by a Mood, Anxiety, or Psychotic Disorder a nd does not meet criteria for Dyspa reun ia.
Code as fo llows:
Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (I f a general medical condit ion is present, it does not have a major role in the onset, severity, exacerbation, o r maintenance of the pain.) This type of Pain Disorde r is not diagnosed if criteria are a lso met for Somatization Disorder.
307.BO
Specify if:
Acute: duration of less than 6 months Chronic: du ration of 6 months o r longer Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the o nset, severity, exacerbatio n, or maintenance of the pain. The associated general med ical cond it ion o r anatomical site of the pain (see below) is coded on Axis III.
307,89
Specify if:
Acute: duration of less than 6 months Chronic: duration of 6 months o r longer Note: The following is not considered to be a mental disorder and is included here to facilitate differential diagnosis. .... , Pain Disorder Associated With a General Medical Condition: a general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation, or ma intenance of the pai n.) The diagnostic code for the pain is selected based on the aS50ciated genera l medical cond ition if one ha s been established (see Appendix G) or on the anatomical location of the pain if the unde rlying general medical conditio n is not yet clearly established- fo r example, low back (724.2), sciatic (724.3), pelvic (625.9), headache (784.0), fa cia l (784.0), chest (786.50), joint (7 19.40), bone (733.90), abdominal (789.0), breast (61 1.7 1), renal (788.0), ear (388.70), eye (379.9 1), th roat (784. 1), tooth (525.9), and urinary (788.0).
1 504
Somatoforrn Disorders
300.7
Diagnostic Features
Hypochondriasis
The essential feature of Hypochondriasis is preoccupation wi th fears of having, or the idea tha t one has, a serious d isease based on a misinterpreta tion of onear more bodily signs or symptoms (Criterion A). A thorough medical evaluation does not identify a general medical condition tha t fully accounts for the p erson 's concerns about disease or for the physical signs or symptoms (although a coexisting general medical condi
tion may be p resent). The unwarranted fear or id ea of having a disease persists despite medical reassurance (Criterion B). H owever, the belief is not of delusiona l intensity (Le., the person can acknowledge the possibility that he or she may be exaggerating the extent of the feared disease, or that there may be no disease at all). The belief is also not restricted to a circumscribed concern about app earance, as seen in Body Dysmorphic Di sorder (Criterion C) . The preoccupation w ith bodily symptoms causes cl in icaUy significant d is tress or impairment in social, occupational, or other important areas of fun ctioning (Cri terion D) and lasts for at least 6 months (Criterion E). The p reoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Majo r Depressive Episode, Separation Anxiety, or ano ther Somatoform Disorder (Criterion F). The preoccupation in Hypochond riasis may be w ith bod ily functions (e.g., heartbeat, sweating, or peris ta lsis); w ith minor physical abnormalities (e.g., a s mall sore or an occasional cough); or with vague and ambiguous physical sensations (e.g., "tired heart, " "aching veins") .111e person attributes these symptoms or signs to the su spected disease and is very concerned w ith their meaning, authenticity, and etiology. The concerns may involve several bod y systems, at different times or Simultaneous ly. Alternatively, there may be preoccupation with a sp ecific organ or a single disease (e.g., fear of having cardiac d isease). Repea ted physical examinations, d iagnostic tests, and reassurance from the physician do little to allay the concern about bodily d isease or affliction. For example, an individual preoccupied w ith having cardiac disease w ill not be reassured by the repeated lack of findin gs on physical examination, ECG, or even cardiac angiogra phy. Indiv iduals with Hyp ochondriasis may become ,? Iarmed by reading or hearing about disease, knowing someone w ho becomes sick, or fro m observations, sensations, or occurrences w ithin their own bodies. Concern about the fea red illness often becomes a central fea ture of the indi vidual's self-image, a topic of social d iscourse, and a res ponse to life s tresses.
Specifier
With Poor Insight. This s pecifier is used if, for mos t of the time during the current episode, the individual does not recognize that the concern about having a serious illness is excessive or unreasonable.
300.7
Hypochondrias is
505 \
on physical health, they generally have no better health habits (e.g., healthy diet, regular exercise, avoidance of smoking) than individuals without the disorder. The medical history is often presented in great detail and at length in Hy pochondriasis. "Doctor-shopping" and deterioration in doctor-patient relationships, with fru stration and anger on both sides, are common . Individua ls with this disorder often believe that they are not getting proper care and may strenuously resist referral to mental hea lth professionals. Complications may result from repeated diagnostic p rocedures that carry their own risks and are costiy. However. because these individuals have a h istory of multiple complaints without a clear physical basis, they may receive cursory eva luations and the presence of a general medical condition may be missed. Social relationships become s tr~ined because the individual w ith Hypochondriasis is preoccupied with his or her condition and often expects special treatment and consideration. Family We may become disturbed as it becomes centered around the individual's physical well-being. Often, the preoccupation interferes with job performance and causes the person to miss time from work. In more severe cases, the individual with Hypochondriasis rna}' become a complete invalid. Serious illnesses, particularly in childhood, and pa st experience with d isease in a family member are associated with the occurrence of Hypochondriasis. Psychosodal stressors, in particular the death of someone close to the individual. are thought to predpitate the disorder in some cases. Individ uals with Hypochondriasis often have other mental disorders (particularly Anxiety, Depressive, and otherSoma toform Oisorders). Associated laboratory findings . Laboratory findings do not confirm the individual's preoccupation. Associated physical examination find ings and general medical conditions . Physical examination findings do not confirm the individual's preoccupation.
Preva lence
The prevalence of Hypochondriasis in the general population is 10/0-5%. Among primary care outpatients, estimates of current prevalence range from 2% to 7%.
1 506
Course
H yp ochondriasis can begin at any age, w ith the most common age at onset thought to be in early adulthood. The course is us ually e1uanic, w ith w axing and waning symptoms, bu t complete recovery sometimes occurs. It appears that acute onset, brief duration, mild hypochondriacal symptoms, the presence of general medical comorbidity, the absence of a comorbid mental disorder, and the absence of secondary gain are favorable prognostic ind icators_ Because of its chronicity, some view this disorder as having p rominent " traitlike" characteristics (i.e., a long-s tanding preoccupation with bodily complaints and focus on bodi ly symptom s).
Differential Diagnosis
The most important differential diagnostic consideration in H ypochond rias is is an underlying general medical condition, such as the early s tages of neurological conditions (e.g., multiple sclerosis or myasthenia gravis), endocrine conditions (e.g., thyroid or parathyroid disease), d iseases that affect multiple body systems (e.g., systemic lupus erythematos us), and occult malignancies. Al though the presence of a general medical condition d oes n ot rule out the possibility of coexisting Hypochondriasis, transien t preoccupations rela ted to a current general medical condition do not cons titute Hypochondriasis. Somatic symp toms (e.g ., abdominal p ain ) arc common in children and should no t be diagnosed as Hypochondriasis unless the child has a prolonged preoccupation w ith having a serious il1ness. Bod ily preoccupations and fears of debili ty may be freq uent in elderly p ersons. However, the onset of health concerns in old age is more likely to be realistic or to reflect a Mood Disorder rather than Hypochondriasis. A number of other disorders may be characterized by concerns about health or illness. H yp ochondriasis is not diagnosed if the individual's health concerns are better accoun ted for by one of these disorders. For example, individuals w ith Generalized Anxiety Disorder worry about a number of events and activities tha t may inclu de worries about ha ving a d isease. A separate diagnosis of Hypochondriasis should be considered only if the preoccupation with ha ving an illness is the individual 's predominant focus of concern. Some individuals in a Major Depressive Episod,e will be preoccu p ied w ith excessive worries over physical health . A separate diagnosis of Hypochondriasis is not made if these concerns occur only d uring Major Depressive Episodes. H owever, depression often occurs secondary to the Hypochondriasis, in which case Hypochondriasis should also be diagnosed . Individuals w ith Hypochondriasis may have intrusive thoughts about ha vin g a disease and also may have associa ted compulsive behaviors (e.g., askin g for reassu rances). A separate diagnosis of Obsessive-Compulsive Disorder is given only when the obsessions or compulsions are not restricted to concerns abou t illness (e.g ., checkin g locks). Occasionally, indi vid uals with H yp ochondriasis experience Panic Attacks that are triggered by hyp ochondriaca l concerns . However, a separate diagnosis of Panic Disorder is made only w hen recurrent unexpected Panic Attacks are also present. In Body Dysmorphic Disorder, the concern is limited to the person's physical appearance. In contrast to a Specific ("disease") Phobia in which the individual is fea rful of developing or being exposed to a disease, Hypochondriasis is char,1cterized by a p reoccupation tha t one has the d isease.
300.7
507
In Hypochondriasis, the disea se conviction d oes not reach delusional proportions (i.e., the individual can entertain the p ossibility that the feared d isease is not p resent), as opposed to somatic delus ions that can occur in Psych otic D isorders (e.g., Schizophrenia, Delusional Disorder, Somatic Type, and Major Depressive Disorder. With Psychotic Fea tures).
matic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder) .
O. The preoccupation causes clinically significant distress or impairment in social, occu-
pational. or other important areas of functi oning. E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxi ety, or another Somatoform Disorder.
Specify if:
With Poor Ins ight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable
3 00.7
Diagnostic Feat ures
The essential feature of Body Dysmorphic Disorder (historically known as dysmorphophobia) is a preoccupation with a defect in appearance (Criterion A). The defect is either imagined, or, if a slight physical anomaly is present, the individual's concern is markedly excessive (Criterion A). The preoccupation mus t cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The preoccupa tion is not better accounted for by another mental disorder (e.g ., d issatisfaction w ith body s ha pe and s ize in Anorexia Nervosa) (Criterion C). Complaints commonly involve imagined or slight fla ws of the face o r head s uch as hair thinning, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, fac ial asymmetry or dis proportion, or excessive facial hair. Other common preoccupations includ e the shape, size, or some other aspect of the nose, eyes, eyelidS, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks, or head . However, an y other body part may be the focus o f concern (e.g., the genitals, breas ts,
508
Somatoform Disorders
buttocks, abdomen, arms, hands, fee t, legs, hips, shoulders, spine, larger body reo gions, overall body size, or body build and muscularity). The preoccupation may simultaneously focus on several body paris. Although the complaint is often specific (e.g., a "crooked" lip or a "humpy" nose), it is sometimes vague (e.g., a " falling" facc or "inadequately finn" eyes). Because of embarrassment over their concerns or for other reasons, some individuals with Body Dysmorphic Disorder avoid describing their "defects" in detail and may instead refer only to their general ugliness. Most individuals with this disorder experience marked dis tress over their s upposed deform ity, oiten describing their preoccupa tions as "in tensely painfu l," " tormenting," or "devastating." Mos t find their preoccupations difficult to control, and they may make little or no attempt to resist them. As a result, they often spend hours a day thinking about their "defect," to the point where these thoughts may dominate their lives. Significant impairment in many areas of functioning generally occurs. Feelings of self-consciousness about their "defect" may lead to avoidance of work, school, or public situations.
300.7
difficulties, or get d ivorced because of their symptoms. The distress and d ysfunction associated with this disorder, although variable, can lead to repeated hospitalization and to suicidal ideation, suicide attempts, and completed suicide. Individuals with Body Dysmorphic Disorder often pursue and receive general medical (often dennatoiogical), dental, or surgical treatments to rectify their imagined or slig ht d efects. Occasionally, indjvjdtla ls may resort to extreme measures (e.g., self-su rgery) to correct their perceived flaw s. Such treatment may cause the d.isorder to worsen, leading to intensified or new preoccupations, which may in turn lead to further unsuccessful procedures, so that individ uals may eventually possess "synthetic" noses, ears, breasts, hips, or other body parts, w hich they are still dissatisfied w ith. Body Dysmorphic Disord er may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, and Obsessive-Compulsive Disorder.
Prevalen ce
The prevalence of Body Dysmorphic Disorder in the commwlity is unknown. In clinic" l mental health settings, reported rates of Body Dysmorphic Disorder in individuals with Anxiety or Depressive Disorders range from under 5% to approximately -10%. In cosmetic surgery and dermatology settings, reported rates of Body Dysmorphic Disorder range from 6% to 15%.
Co urse
Body Dysmorphic Disorder usuall}' begins during adolescence but can begin during childhood. However, the disorder may not be d.iagnosed fo r many years, o ften becali se individuals w ith the disorder are reluctant to reveal their symptoms. The onset may be either gradua l or abrupt. The di sorder often has a fairly continuous course, with few symp tom-free in tervals, although the intensity of symptoms may wax and wane over time. The part of the body on which concern is focused may remain the same or may change.
510
Somatoform Disorders
should be differentiated from healthy e~ ercising and from excessive exercising tha t may occur as part of an Eating Disorder. The diagnosis of Body Dysmorphic Disorder should not be made if the preoccupation is better accounted for by another mental di sorder. Body Dysmorphic Disorder should not be diagnosed if the excessive preoccupation is restricted to concerns about "fa tness" in Anorexia Nervosa, if the individual's preoccupation is limited to d iscomfort w ith or a sense of inappropriateness about his or her primary and secondary sex cha racteris tics occurring in Gender Identity Disorder, or if the preoccupation is limited to mood-congnlcnt ruminations involving appearance that Deem exclusively during a Major Dep ressive Episode, However, dep ression often occu rs secondary to Body Dysmorphic Disorder, in which case Body Dysmorphic Disorder should be diagnosed . Individuals wi th Avoidant Personality Disorder or Social Phobia may worry about being embarrassed by real defects in appearance, but this concern is usua U not y p rominent, p ersisten t, distreSSing, time consumi.ng, and impairing. Although individuals with Body Dysmorphic Disord er have obsessional preoccupations abou t their appearance and may have associated com pulsive behaviors (e.g., mirror checking), a sepa rate diagnosis of Obsessive-Compulsive Disorder is gi ven only when the obsessions or compulsions are not restricted to concerns abou t appearance. Some individuals with Bod y Dysmorphic Disorder remove body hair or pick their skin in an attempl 10 improve their appearance; these behaviors should be distinguished from hair pulling in Trichotillomania, which does not occur in response to appea rance concerns, and from skin picking tha t may be associated with other mental disorders. Individuals with Body Dysmo rphic Disorder can receive an additional diagnosis of Delusional Disorder, Somati c Type, if their preoccupation with an imagined defect in appearance is held with a delusional intensity. Koro is a culture-related syndrome that occurs primarily in Southeast Asia tha t may be related to Body Dysmo rphic Disord er. It is characterized by the preoccupation that the penis (or labia, nipples, or breast in women) is shrinking or retracting and will di sappear into the abdomen . This preoccupation is often accompanied by a belief that death will result. Koro differs from Body Dysmorphic Disorder by its usually brief d uration, different associated features (primarily acu te anxiety and fear of death), positive response to reassurance, and occasional occurrence as an epidemic.
300.82
signs of pregnancy, w hich may include abdominal enlargement (although the umbil icus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal m ovement, nausea, breas t engorgement and secretions, and labor pains at the expected d ate of delivery. End ocrine chan ges may be present, but the syndrome cannot be explained by a general medical condi tion tha t causes endocrine ch anges (e.g., a ho rmone-secreting tumor). 2. A disorder in volv i.n g non psychotic hypochondriacal symptoms o f less than 6 months' dLUation. 3. A d isorder involving unexp lained physical complaints (e.g., fa tigue or body weakness) of less than 6 months' dLUation that are not due to another mental disorder.
Factitious Disorders
<'ctiticus Disorders a TC characterized by physical or psychological symptoms that arc intentionally produced o r feigned in order to assume the sick role. The judgment that a particular symptom is intentionally produced is made both by direct evidence and by excluding other causes of the symptom. For examp le, an individual presenting with hematuria is found to have anticoagulants in hi s possession. The person d en ies h av ing taken them, bu t blood s tu d ies are consis tent w ith the ingestion of anticoagulan ts. A reasonable inference, in the absence of evidence that acciden tal ingestion occurred, is that the individual may have taken the med ication in tentionally. It should be noted Ula! the presence of factitious symptoms d oes not preclude the coexis tence of true physical or psychological symptoms. Factitious Disorders are dis tinguished from acts of Malingering. In Malingering, the individual also produces the symptoms intentionally, but has a goal that is obviously recognizable when the environmental circums ta nces are known. For example, the intentional production of symptoms to avoid jury duty, s tanding trial, or conscription into the mili tary would be classified as Ma lingering. Similarly, if an individual who is hospitalized fo r treatment of a men tal disorder simu lates an exacerbation of illness to avoid transfer to another, less desirable fa cility, this would be an act of Mali ngering. In contrast, in Factitious Disorder, the motivation is a p sychological need to ass ume the sick role, as evidenced by an absence of external incentives for the behavior. Malingering may be considered to be adaptive under certain circums tances (e.g., in hostage situations), bu t by d efinition a diagnosis of a Factitious Disorder a lways implies psychopathology.
Factitious Disorder
The essential feature of Factitious Disorder is the in tentional production of physical or psychological signs or symptoms (Criterion A). The presentation may includ e fabrication of subjective compla ints (e.g., complaints of acute abdominal pain in the absence of an)' s uch pain), falsifica tion of objective signs (e.g., manipulating a thermometer to create the illusion of fever), self-inflicted conditions (e.g., the production of abscesses by injection of saliva into the s kin), exaggeration o r exacerbation of preexisting general medical conditions (e.g., feigning of a grand mal seizlUe b y an individual with a previous his tory of seizure di sorder), or any combination or variation of these. The motivation for the behavior is to assume the sick role (Cri terion B). External incentives for the behavior (e.g., economic gain, avoiding lega l responsibiH ty, or improv ing physical well-being, as in Malingering) arc absent (Criterion C). Ind iv iduals with Factitious Disorder usuaUy present their h istory w ith dramatic flair, bu t are extremely vague and inconsistent when qu estioned in g reater detail.
513
514
They may engage in pathological lying, in a manner that is intriguing to the listener, Clbout an y aspect of their history or symptoms (Le., pseudologia fanl.lslica). They oftcn have extensive knowled ge of medical terminology a nd hospital rou tines. Complaints of pain and requests for analgesics are vcry common. After an extensive workup of their initial chief complaints has proved negative, they o ften complain of
other physical or psychologica l problems and produce more fa ctitious symptoms.Indi vid uals w ith this disorder may eagerly undergo multiple invasive p rocedures and operations. While in the hospital, they usu ally have few visitors. Eventually, a point may be reached a t which the factitious nature of the individual's symptoms is revealed (e.g., the person is recognized by someone who encoun tered the patient during a previous admission; other hospitals confirm multip le prior hospitalizations for fac titious symptoma tology). When confronted with e\idence that their symptoms are fac titious, individuals w ith this d isorder usually deny the allegations or rapid ly d ischarge themselves aga inst medica l advice. Sometimes, they w ill be admitted to a nother hospital soon after. Their repeated hospitalizations may take the m to numerous cities, s tates, and countries.
Subtypes
Factitious Di sorde r is coded according to the s ubtype that best characterizes the pred ominant sym p toms. 300.16 With Predom inantl y Psychological Signs and Symptoms. This subtype describes a clinical presenta tion in which psychological signs and symptoms p red ominate. It is characterized by the intentional production or feigning of psychological symptoms that are s uggestive of a mental disorder. The ind iv idual's goal is appa rently to assume the " patient" role and is not othe rw ise understa ndable in light o f environme ntal ci rcumstances (in contras t to the case in Ma lingering). This s ubtype may be suggested by a Wide-ran ging symptomatology tha t often does not correspond to a typical syndromal pattern, an unusual course and response to treatment, and th e worsening o f symptoms w he n the individual is aware of being observed . Individuals with this s ubtype of Factitious Disorder may cla im problems s uch as de pression and suicid al ideation follOWing the death o.f a sp ouse (the death not being confirmed by other informan ts ), memory loss (recent and remote), hallucinations or delusions, symptoms of Posttraumatic Stress Disorder, and dissociative symptoms. Some individuals may discern from the examiner's questions the symptoms to endorse during a review of syste ms. Con versely, they may be extremely negativistic and uncooperative when questioned . The p resentation usually represents the indiv idual's concept of mental disorde r and may not conform to any recognized diagnostic category. 300.19 With Predominantly Physical Signs a n d Symptoms. This subtype describes a clinical presen tation in w hich signs and symptoms of an apparent genera l medical condition predomin<"!te. Comm on clinical problems tha t may be feigned or produced include infection (e.g., abscesses), impaired wound healing, pain, hypoglycem ia, anemia, bleedi ng, rashes, ne urological symptoms (e.g., seiZures, dizziness, o r blacking out), vomiting, diarrhea, fevers of
undetennined origin, and symptoms of automlmune or connective tissue disease. The mos t severe and chronic form of this disorder has been referred to as '?vh.inchausen 's syndrome," consis ting of the core elements of recurrent hosp italization, peregrination (traveling), and pseudologia fanla s tica . All organ systems are potential targets, and the symptoms presented are limited only by the indiv idual's medical knowledge, sophistication, and imagination. 300.19 With Comb ined Psychological and Phys ical Signs and Symptoms . This subtype describes a clinical presentation in which both p sychological and physical signs and symptoms are present, but neither p redominates.
, ..
Specifi c Gender Features
Factitiou s Disorder is more common in females than in males. However, the most chronic and severe (Munchausen) variant appea rs to be more frequ ent in males than in females.
Prevalence
There is limited information on the prevalence of Factitious Disorder. Standard epidemiological techniques are constrain ed by the fact that Factitiolls Disorder always involves deception and sometimes peregrination as well, and so it often may not be recognized. On the other hand, the chronic form of the diso rder may be overreported because affected individuals appear to different physicians at different hospitals, of-
516
Factitious Disorders
ten under different names. The best d ata indicate tha t, with in large general hospi tals, Factitious Disorder is diagnosed in around 1% of patients on whom m ental health p rofessionals consult. The p revalence appears to be grea ter in highly specialized trea tment settings. Presenta tions with Predominantly Psydlo logicaJ Signs and Symptoms are reported much less commonly than those w ith Pred ominantly PhYSica l Signs and Symptoms.
Course
The course of Factitious Disorder u sually consis ts of interm ittent episodes. Less common is a single episode or chronic, unremitting illness. The onset is usually in earl y ad u lthood, often after a hospitalization for a general medical condition or o ther mental d isorder. in the chronic form of this disorder, a pattern o f su ccessive hospitalizations may become a lifelong pattern.
300 .1 9
517 \
300.16 With Predominantly Psychological Signs and Symptoms: if psychological signs and symptoms predominate in the clinical presentation 300.19 With Predominantly Physical Signs and Symptoms: if physical signs and symptoms predominate in the clinical presentation 300.19 With Combined Psychological and Physical Signs and Symptoms : if both psychologica l and physical signs and symptoms are present but neither predom inates in the clinical presentation
Dissociative Disorders
T he essential feature of the Dissociative Disorders is a disruption in the usua lly integrated functions of consciousness, memory. identity, or perception. The d isturbance may be sudd en o r gradual, transient or duonic. The following disorders arc included in thi s section: Dissociative Amnesia is characterized by an inability to recall important personal informa tion. usually of a traumatic or stressful nature, tha t is too extensive to be explained by ordinary forge tfulness. Dissociative Fugue is char,1cte rized by sudden, unexpected travel away from home or one's customary p lace of work, accompanied by an inabili ty to recall one's past and confusion about personal identity or the assumption of a new iden tity . Dissociative Identity Disorder (formerly Multiple Personali ty Disorder) is characterized by the presence of two or more di stinct identities or persona lity s tates tha t recurrently take control of the individual's behavior accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfuln ess. It is a disorder characteri zed by iden tity fragmentation rather than a proliferation of sepa rate personalities. Depersonalization D iso rder is characterized by a persis tent or recurrent feeling of being detadled from one's men tal processes or body that is accompanied by intact reality tes ting. Dissociative Disorder Not Othenvise Specified is included for codin g disord ers in which the predominant feature is a dissociative symptom, but that do not meet the criteria for any specific Di ssociative Disorder. Di ssociative symptoms are also included in the criteria sets for Acute Stress Disorder, Posttraumatic Stress Disorder, and Somatization Disorder. An additional Dissociative Disorder diagnosis is not given if the dissociative symptoms occur exclUSively during the course of one o f these disorders. In some classifications, conversion reaction is considered to be a d.issociative phenomenon; howeVer, in DSM-TV, Conversion Disorder is p laced in the "Somatoform Disorders" section to emphasize the importance of considering neurological o r other general medical conditions in the differential diagnosis_ A cross-Cllitural perspective is particularly importa nt in the eva luation of Dissociative Disord ers because dissociative s tates are a common and accepted expression of cultural activities or religious experience in many societies_ In most such ins tances, the dissociative s tates are not pathologica! and do not lead to Significa nt distress, impairment, or help-seeking behav ior. However, a number of culturally defined syndromes characterized by d issociation do cause distress and impairment and are recOgnized indjgenously as mani fes tations of pathology (see p_ 783 and p. 897), although the symptomatology may take different form s in different cultures, such as recurrent b rief episodes o f dissociative s tupor or spirit possession in Lndia_
519
520
consciousness). The disturbance does not occur excluSively during the course of Dissocia tive Identity Disorder, Dissociative Fugue, Posttraumatic Stress Disorder. Acute
Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a subs tance or a neurologica l or other general medical condition (Criterion B). TIle symp toms must cause clinica lly significant d is tress or impairment in socia l, occupational, or other important areas of functi oning (Criterion C) . Dissociative Amnesia most conunonly presents as a retrospectively reported gap or series of gaps in recall for aspects of the individual's life h istory. These gaps are us ually rela ted to traumatic or extremely s tressful events. Some individuals may have amnesia fo r episodes of self-mutilation, violent outbursts, or s uicide attempts. Less common ly, Dissocia tive Amnesia presents as a fl orid episode w ith s udden onset. This acute form is more likely to occur during wartime or in response to a natura l disaster or other fo rms of severe trauma. Several types of memory dis turbances have been described in Dissociative Amnesia. In localized {II/mesia, the individual fails to recall events that occurred during a circumscribed period of time, us ually the first few hours following a profound ly disturbing event (e.g ., the uninjllTed Slm ' ivor of a car acciden t in which a f,1 mily member has been killed may not be able to recall anything that happened from the time of the accident until 2 d a}'s later). In selective allllll!sia, the person can recall some, but not all, of the events during a circumscribed period of time (e.g., a comba t veteran can recall only some parts of a series of v iolent combat experiences). Three other types of amnesia-generalized, continuous, and systematized- are less common. In gelleralized alllllesia, fai lure of recall encompasses the p erson's entire life. Indi vid uals with this rare disorder usually present to the police, to emergency rooms, or to general hospita l consultation-liaison services. ContinI/OilS allllles;a is d efined as the inabili ty to recall events subsequent to a specific time up to and including the presen!. Systematized amllesia is loss of memory for certa in ca tegories of information, such as all memories relating to one's family or to a particular person. Individuals who exhibit these latter three types of Dissociative Amnesia may ultimately be diagnosed as having a more comp lex form of Dissociative Disorder (e.g., Dissociative Iden tity Disorder).
300. 12
accurate ans wers to questions (e.g., "2 plus 2 equals 5") as in Ganser syndrome. Other problems that sometimes accompany this disorder include sexual dysfunction, impairment in work and interpersonal relationships, self-mutilation, aggressive impulses, and su icidal impulses and acts. Individuals with Dissociative Amnesia may also have symptoms tha t meet criteria fo r Conversion Disorder, a Mood Disorder, a SubstanceRelated Disorder, o r a Personality Disorder. Associated laboratory findings . Individua ls wi th Dissociative Amnesia o h en display high hypnotizability as measured by standardized tes ting .
Preval en ce
In recent years, there has been an increase in reported cases of Dissociative Amnesia that involves previously forgotten early childhood traLUnas. This increase has been subject to very different in terpretations. Some believe that the greater awareness of the diagnosis among mental health profeSSionals has res ulted in the identification of cases that were previously undiagnosed. in contras t, others believe that the syndrome has been overdiagnosed in individuals w ho are highly suggestible.
Course
Dissociative Amnesia can present in any age grou p, from young children to adults. The main manifestation in most individuals is a retrospective gap in memory. The reported d uration of the events for which there is amnesia may be minutes to years. Only a single episode of amnesia may be reported, although two or more episodes are also conunonJy described . Individuals who have had one ep isode of Dissociative Amnesia may be predisposed to develop amnesia for subsequent traumatic circumstances. Acute amnesia may resolve spontaneously after the individual is removed from the traumat ic circLUllsla nces wilh which the amnesia was associated (e.g., a soldier with localized amnesia after several days of intense combat may spontaneously regain memory of these experiences after being removed from the battlefield). Some individuals with ch ronic aOUlesia may g rad ually begin to recall dissociated memories. Other individuals may d evelop a chronic form of amnesia.
Differential Diagnosis
Dissociative Amnesia mus t be d istinguished from Amnestic Disorder Due to a General Medi cal Condition, in which the amnesia is judged to be the direct physiological
522
Dissociative Disorders
consequence o f a s pecific neurological or other general medical condition (e.g., head trauma, epilepsy) (see p. 175). Thi s d etermination is based on history, laboratory findings, or physical examination . [n Amn esti c Di sorder Due 10 a Brain lnju ry, the disturbance of recall, though circumscribed, is often both retrograde (i.e., encompassing a period of time before the head trauma) and anterograde (Le., for events after the trauma), and there is usually a history of a clear-cut physical traum a, a period of unconsciousness, or clinical evidence of brain injury. In contrast, in Dissociative Amnesia, the dis turbance of recall is almost always anterograde (i.e., memory loss is restricted to the period after the trauma), and there are typically no prob lem s with leanling new in fo rmation. The ra re case of Dissocia tive Amnesia with retrograde amnesia can be d isting uished by the diagnostic use o f hypnosis; the prompt recovery of the lost memories suggests a dissociative basis for the d isturbance. In seizu re d iso rders, the memory impairment is sudden in onset, motor abnormalities may be present. and repeated EEGs reveal typical abnormalities. In d eliriu m and dementia, the memory loss for personal infomlil tion is embed ded in a far more extensive set of cognitive, linguistic, affective, a ttentional, perceptual, and behavioral d isturbances. In contras t, in Dissociative Amnesia, the memory loss is primarily for autobiographical infonnation and cognitive abilities generally are preserved. The amnesia associated with a genera l medical cond ition us ually cannot be reversed. Memory loss associated with the use of subs tances or medica tions m ust be dis tinguis hed from Dissociative Amnesia. Subs tan ce-In d uced Pe rsis ting Amnestic Disord er should be diagnosed if it is judged that there is a persis tent loss of memory that is related to the direct physiological effects of a s ubs tance (e.g., a drug of abuse or a medication) (see p. 177). Whereas the ability to lay down new memories is preserved in Dissocia tive Amnesia, in Substance-Induced Persisting Amnes tic Disord er, shortteml memory is impaired (Le., events may be recalled immediately after they occur, but not after a few minutes h ave passed). Memory loss associated with Su bs tance Intoxica tion (e.g., "blackouts") can be d istinguis hed from Dissociati ve Amnesia by the association of the memory loss with heavy subs tance use and the fact that the amnesia usually cannot be reversed. The dissociative symptom of amnesia is a characteristic fea ttue of both Dissociative Fugue and Dissociative Identity Disorder. Therefore, if the dissociative amnesia occurs exclusively during the course of Dissociative Fugu e or Dissocia tive Identity Disorde r, a separa te d iagnosiS of D i ssociati"~ Amnesia is not made. Because depersonalization is an associated feature o f Dissociative Am.nesia, d ep ersonalization that occurs only during Dissocia tive Amnesia should no t be diagnosed separately as Deperson alization Disord er. In Posttraum atic Stress Disorder and Acu te Stress D isorder, there can be amnesia for the traumatic even t. Similarly, dissociative symptoms such as amnesia are included in the criteria set fo r So matiza tion Di so rd er. Dissociative Amnesia is not diagnosed if it occurs exclusively duri.ng the course of these disorders. Malingered amnes ia is most common in individuals presenting with acute, florid symptoms in a context in w hich potential secondary gain is eVident-faTexample, fi nancial or lega l problems or the desire to avoid combat, although tnle amnesia may also be associated with such stressors. Furthermo re, individuals with true Dissoci ative Amnesia uSllally score high on s tandard m easures of hypnotizability and d issociative capacity.
300.13
523 /
Care must be exercised in evaluating the accurac), of retrieved memories. There has been considerable controversy concerning amnesia related to reported physical or sexual abuse, particularly when abuse is alleged to have occurred during early childhood. Some clinicians believe tha t there has been an lmderreporting of s uch e\'ents, especially because the victims are often children and perpetrators are inclined to deny or dis to rt their actions. However, other clinicians are concerned that there may be overreporting, particularly given the unreliability of childhood memories. There is currently no method for establishing w ith certainty the accuracy of such re~ trieved memories in the absence of corroborative evidence. Dissociative Amnesia must also be differentiated from memory loss related to Age-Related Cogniti ve Decline and non patholog ical forms of amnesia including everyday memory loss, posthypnotic amnesia, infantile and childhood amnesia, and amnesia for sleep and dreaming. Dissociative Amnesia can be distinguished from normal gaps in memory by the extensive and involuntary nature of the inability to recall the conten t of the lost memory (i.e., memories of it traumatic nature) and by the presence of significant distress or impainnent.
524
Dissociative Disorders
Travel may range from brief trips over relatively short periods of time (Le., hours or days) to complex, usually unobtrusive wandering over long time periods (e.g., weeks or months), with some ind ividuals re portedly crossing numerous national borders and traveling thousands of miles. During a fug ue, ind ividuals may appear to be w ithout psych opathology and generally d o not a ttract atten tion. At some point. the individual is brought to clinical attention, usually beca use of amnesia for recent events or a lack of aw areness of personal identity . O nce the individual returns to the prefu gue state, there may be no memory fo r the events that occurred during the
fugue.
Most fu gu es d o not involve the fonnation of a new identity. If a new identi ty is assumed du ring a fu gue, it is usually characterized by more gregarious and uninhibited trai ts than characterized the former identi ty. The person Dlay assume a new name, take up a new residence, and engage in complex social acti\' ities that are well integrated and that d o not suggest the presence of a mental disord er.
Preva lence
A prevalence rate o f 0.2% for Dissocia tive Fugue has been reported in the general population . The prevalence may increase during times of extremely stressful even ts such as wartime or natural disaster.
300.13
Co urse
The onset of Dissociative Fug ue is usually related to traumatic, stressful, or over whelming life events. Most cases are described in adults. Single episodes are most commonly reported and may last from hours to months. Recovery is usua lly rapid, but refractory Dissociative Amnesia may persist in some cases.
Dissociative Disorders
B. Confu sion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during t he course of Dissociative Identity Disorder and is not due to t he direct physiological eHects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically sig nificant distress or impairment in social, occupational, or other important a reas of functioning.
300.14 Dissociat ive Identity Disorder (formerly Mu lt ipl e Persona lity Disorder)
527
or visual hallucinations (e.g ., a voice gl\' ing instructions) . Evidence of amn esia may be uncovered by reports from others who have witnessed behav ior that is d isavowed by the individual or by the ind ividual's own discoveries (e.g., finding items of dothing at home tha t the ind ivid u al cannot remember havin g bought). There may be loss of memory n ot only fo r recurrent periods o f time, but also an overall loss of biographical memory for some extended period of childhood , adolescence, or even ad ulthood . Transition s among iden tities are often triggered by psychosocial stress. The time required to switch from one identi ty to another is usually a ma tter of seconds, but, less frequently, may be gradual. Behavior that may be frequentl}' associated with identity switches include rapid blinking, facia l changes, changes in voice or d emeanor, or disruption in the ind ividua l's train of thoug hts. The nu mber of id entities rep orted ranges from 2 to more than 100. Half of reported cases include ind ividuals with 10 or fewe r identities.
528
Specific Culture, Age, and Gender Features
Dissociative Di sorders
Dissociative Ide ntity Disorder has been found in individuals from a variety of cultures around the world . In preadolescent children, particular ca re is needed in making the diagnosis because the manifestations may be less distincti\'e than in
Prevalence
The sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very differen t interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed . In contrast, others believe that the syndrome has been overdiagnosed in individuaJs who a re h.igh ly suggestible.
Course
Dissociative Identity Disorder appears to have a flu ctuating clinical course that lends to be chronic and recurrent. The average time period from first symptom presentation to diagnosis is 6-7 years. Episod ic and continuous courses ha ve both been d escribed. TIle disorder may become less manifest as individuals age beyond their late 40s, but may reemerge during ep isodes of stress or trauma or with Substance Abuse.
529
Symptoms caused by the direct physiological effects of a s u bstance can be d istinguished from Dissociative Identity Disord er by the fact that a substance (e.g., a d rug of abuse or a medication) is judged to be etiologically related 10 the disturbance (see p. 209). The diagnosis of Dissociative Identity Disorder takes precedence over Dissociative Amnesia, Dissociative Fugue, and Deperson alization Disorder. Ind ivid uals with Dissociative Identity Disorder can be dis tinguis hed fro m th ose with trance and possession trance symptoms tilat w ould be diag nosed as Dissociative Disorder Not Oth envise Specified by the fa ct that those with pa thologica l trance and possession trance symptoms ty p ically describe extem al spirits or entities that have entered tileu bodies and taken control. The d ifferential d iagnosis between Dissociative Identity Disorder and a variety of other mental disorders (including Schizophrenia and other Psychotic Disorders, Bipolar Disorder, Wilh Rapid Cycling, Anxiety Disorders, Somatization D isorders, and Personality Disorders) is complicated by the apparently overlapping symptom presentations. For exa mp le, the presence of more than o ne dissociated personality state may be m istaken fo r a d elusion or the communication from one identity to another may be m istaken for an auditory hallucination, leading 10 confusion with the Psychotic Disorders, and s hifts between identity states may be confused w ith C),dical mood fluctuations leading to confusion w ith Bipolar Disorder). Factors that may support a diagnosis of Dissociative Identity Disorder are the p resence of clear-cut dissocia tive symptomatology w ith sudd en shifts in identity s tates, the p ersistence and consistency of identity-specific demeano rs and behaviors over time, reversible amnesia, evidence of dissociative behavior that p redates the clinical or forensic p resentation (e.g., reports by family or co-workers), and high scores on measures of d issociation and hypnotizability in individuals who d o not have the characteristic p resentations of another mental disorder. Dissociative Identity Disord er mus t be distinguished from M alingering in situations in which there may be financial or forensic gain and from Factitious Disorder in w hich there may be a pattern o f helpseeking behavior.
plained by ordinary forgetfulness . D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or cha ot ic behavior during A!cohollntoxication) or a general med ical co n ~ dit ion (e.g ., complex partial seizures). Note: tn children, the symptoms are not attributable to imaginary playmates or other fantasy play.
530
Dissociative Disorders
300.6
Diagnostic Features
Depersonalization Disorder
The essential features of Depersonalization Disorder are persistent or recurrent episodes of depersonalization characterized by a feeling of detachment or estrangement from one's self (Criterion A). The individual may fee l like an automaton or as if he or she is living in a dream or a movie. There may be a sensation of being an outside observer of one's mental processes, one's body, or parts of one's body. Various types of
531
Prevalen ce
The lifetime p reva lence of Depersonalization Disorder in community and clinical settings is W\know n. At some time in their lives, app roxima tely half of all adults may ha\'e experienced a single brief episod e o f depersonalization, u sually p recipitated by se\'ere stress. A transient experience of depersonalization develops in nearly onethird of ind ividuals exposed to life-threatening danger and in close to 40% of patients hospitalized for mental disorders.
Course
lndi\' id uals with Depersonalization Disorder usually present (or treatment in adolescence or adulthood, although the disorder may have an und etected onset in child hood . The mean age at onset has been reported to be around age 16. Because dcpersonaHza tion is rarel y the p resenting complaint, ind ividua ls wi th recurren t depersonaliza tion often present with another symptom such as anxiety, panic, or depression. Duration of ep isod es of d epersona lization can vary from very brief (seconds) to persistent (years). Depersonali za tion subsequen t to IHe-threatening situations (e.g., military combat, traumatic accidents, being a victim o( violent crime) usua lly develops suddenly on exp osure to the trauma, and trauma h istories are often associated w ith this d isorder. The cou rse is usu ally chronic and may wax and wane in intensity but is also sometimes episodic. Most often the exacerbations occur in association with actual or perceived stressful events.
Differential Diagnosis
Depersona liza tion Disorder m ust be d istinguished from symptom s that arc d u e to the physiological consequen ces of a specifi c general m edi c.. l cond ition (e.g., epilepsy) (see p. 181). This determination is based on h istory, labora tory find ings, o r physical examin a tion. D epersonalization t hat is caused b y the direc t ph ysiological effects of a substance is d istinguished from Depersonalization Disord er by the fact that a substance (e.g., a drug of abuse or a medication) is judged to be etiologically related to the depersonaliza tion (see p . 209). Acu te Intoxication or Withdrawal from alcohol and a variety of other substances can result in depersonalization. On the other hand, substan ce use m ay intensify the symp toms of a preexisting Depersonalization Disorder. Thus, accurate diagnosis of Depersonalization Disorder in individuals w ith a h istory of a lcohol- or substance-induced d epersonalization shou ld in clud e a longitud inal h istory of Substance Abuse and depersonalization sym p toms. Depersona liza tion Disorder should not be diagnosed separately w hen the symptoms occur only d uring a Panic Attack that is part o f Panic D isorder, Social or
532
Dissociative Disorders
Speci fi c Ph obia, OT Posttraumatic o r Acute Stress Disorders. In contrast to Schizop hren ia, intact reality testing is maintained in Depersonaliza tion Disorder. The feel ing of numbness associated \\'ith depersona liza tion may mimic a d epression. However, feelings of numbness in individuals wi th Depersonaliza tion Disorder are associated w ith other man ifestations of depersonalization (e.g., a sense of detachment from one's selt) and occur even when the individual is not depressed.
D. The depersonalization experience does not occur exclusively during the course of another menta l disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g ., a drug of abuse, a medication) or a ge neral medical condition (e.g., temporal lobe epilepsy).
300.15
533
mo\'ements or amnesia and is perhaps the most common Dissociative Disorder in Asia. Examples include nmok (Indonesia), bebnillnn Ondonesia), Intalt (Malaysia), pib/oktoq (Arctic), ataqlle de lIervios (Latin America), and possession (India). The dissociative or trance disorder is not a normal part of a broadly accepted col lective cultu ral or religious practice. (See p. 785 for suggested research criteria.) 5. Loss of consciousness, stupor, or coma not athibutable to a general medical condition. 6. Ganser syndrome: the giving of approximate answers to questions (e.g., " 2 plu s 2 equals 5") when not associated with Dissociative Amnesia or Di ssociative Fugue.
section contains the Sexual Dysfunctions, the Paraphilias, and the Gender Identity Disorders. The Sexual Dysfun cti ons are characterized by disturbance in sex-
Th iS
ual desire and in the psychophysiologicaJ changes that characterize the sexual response cycle and cause marked d istress and interpersonal difficulty. 111e Sexual
Dysfun ctions include Sexual Desire Disorders (i.e., Hyp oac tive Sexual Desire Disorder, Sexua l Ave rsion Di sorder), Sexu al Arousal Disorders (i.e., Fema le Sexual Arous-
Sexual Dysfunctions
A Sexual Dysfu nction is characterized by a disturbance in the processes that characterize the sexual response cycle or by pa in associated w ith sexual in tercourse. The sexual response cycle can be divided in to the follow ing phases:
535
536
1. Desire:
lltis phase consists of fantasies a~out sexual activity and the desire to have sexual activity. 2. Excitement: This phase consists of a subjecti ve sense of sexual pleasure and accompanying physiologica l changes. The major changes in the male consist of penile hunescence and erection. The major changes in the female consist of V.lsocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genitalia. 3. Orgasm: Thi s pha se consists of a peaking of sexual pleasure, with release of scxualtension and rhythmic contraction of the perineal muscles and reproductive organs. In the male, there is the sensation of ejaculatory inevitabili ty, which is followed by ejaculation of semen. In the female, there are contractions (not always subjectively experienced as such) of the wall of the outer third of the vagina. In both genders, the anal sphincter rhythmically contracts. 4. Reso/rlfioll : This phase consists of a sense of muscular relaxation and general well-being . During this phase, males are physiologically refractory to further erection and orgasm for a variable period of time. In contrast, fema les may be able to respond to additional stimulation almost immediately. Disorders of sexual response may occur at one or more of these phases. Whenever more than one Sexual Dysfunction is present, all are recorded. No attempt is made in the criteria sets to specify a minimum frequency or range of settings, activities, or types of sexua l encOlmters in which the dysftmction must occur. This judgment must be made by the clinician, taking into accOlmt SUell factors as the age and experience of the individual, frequency and chronicity of the symptom, subjecti ve distress, and effect on other areas of functioning . The words "p ersis ten t or recurrent" in the diagnostic criteria indicate the need for such a clinical judgment. If sexual stimulation is inadequate in either focus, intensity, or duration, the diagnosis of Sexual Dysfunction involving excitement or orgasm is not made.
Subt ypes
Subtypes are provided to indicate the onset, context, and etiological factors associated with the Sexual Dyshmctions . If multiple Sexua l Dys function s are p resent, the appropriate subtyp es for each may be noted. These subtypes do not apply to a diagnosis of Sexual Dysfunction Due to a General Medical Condition or Substance-Induced Sexual Dysfunction. One of the follOWing subtypes may be used to indicate the nature of the onset of the Sexual Dysfunction: Lifelong Type. This subtype applies if the sexual d ysftmction has been present since the onset of sexual ftmctioning. Acq ui red Type. 1l1is subtype applies if the sexual dyshmction develops only after a period of normal functionin g. One of the follOWing subtypes may be used to indicate the context in which the Sexual Dysfunction occurs: Generali zed Type. This subtype applies if the sexual d ysfunction is not limited to certain types of s timulation, sihla tions, or partners.
S exual Dysfunctions
537
Situati ona l Typ e. This subtype applies if the sexual dysfun ction is limi ted to certain types of stimulation, situations, or partners. The specific situational pattern of the dysfu nction may aid in the d iffe rential diagnosis. For example, normal mastu rbatory function in the p resence of impaired partner relational functioning would sugges t that a chief complain t of erectile dysfunction is more likely due to an in terpersonal or intrapsychic problem rather than attributable to a general medical condition or a substance. One of the foUowing subtypes may be used to indicate etiological factors associated with the Sexual Dysfunction: Du e to Psychological Fa ctors. This subtype applies when psychological factors are judged to have the major ro le in the onset, severity, exacerbation, or main tenance of the Sexual Dysfunction, and general medical conditions and substances play no role in the etiology of the Sexual Dysfunction . Due to Com bined Factors. Thi s subtype applies when 1) psychological factors are judged to have a role in the onset, severity, exacerba tion, or maintenance of the Sexual Dysfunction; and 2) a general medical condition or substance use is also judged to be contributory b u t is not sufficient to accoun t for the Sexual Dysfunction. If a general medical condition or substance use (including medication side effects) is sufficient to account for the Sexual Dysfunction, Sexual Dysfunction Due to a General Medical Condition (p. 558) and / or Substance-Ind uced Sexual Dysfunction (p. 562) is diagnosed.
Prevalence
There are few systematic epidemiological data regarding the p revalence of the various sexua l dyshmctions, and these show extremely wide variabil ity. probably reflecting d iffe rences in assessmen t method s, definitions used, and cha racteristics of sampled populations. The most comprehensive sun'ey to d ate, conducted on a representa tive sample of the U.s. population between ages 18 and 59, suggests the fol -
538
lowing prevalence estimates for various sexual complaints: 3% for male dyspareunia, 15% for female dyspareunia, 10% for male orgasm problems, 25% for female orgasm
problems, 33% for female hypoactive sexual desi re, 27% for p remature ejaculation, 20% for female arousal problems, and 10% for male erectile d ifficu lties. Male erecti le problems also increase in prevalence after age SO. It is unclear whether these sexual complaints would have met diagnostic criteria for a DSM-IV Sexual Disorder. Estimates of prevalence rates for sexual aversion, vaginismus, sexual d ysfun ctions d ue to a general medical condition, and s ubstance-induced sexual dys functions are not available.
fects of a s pecified general medical condition, the diagnosis is Sexu al Dysfun cti on Due to a General Med ical Condition (p. 558). nl is determination is based on history, laboratory findings, or ph ysica l examination . If the Sexual Dysfunction is judged to be caused exclusively by the physiological effects of a drug of abuse, a medication, or toxin exposure, the diagnosis is Substan ce-Induced Sexu al Dysfunctio n (see p. 562). The clinician shou ld inquire ca refully about the nature and extent o f substance use, incl uding medications. Symptoms that occur during or shortly after (i.e., within 4 weeks 00 Subs tance Intoxication or a fter medication lise may be especially indicative of a Substance-Indu ced Sexual Dysfunction, depending on the type or amOWl t of the substance used. or the duration of use. lf the clinician has ascertained that the sexual dysfunction is due to both a general medical condition and substance use, both diagnoses (Le., Sexual Dysfunction Due to a General Medica l Condition and Subs tance-Induced Sexual Dysfunction) can be given. A p rimary Sexu al Dysfunction diagnosis with the subtype Due to Combined Factors is made if a combination of psychological fac tors and either a general med ical condition or a substance is judged to have an etiologica l role, but no one etiology is sufficient to account for the d ysfunction. If the clinician cannot determine the etiological roles of psychological factors, a general medical condition, and substance use, Sexu al Dysfu nction N ot Olhen vise Specified is diagnosed. The diagnosis of a Sexual DysfWlction is also not made if the dysfunction is better accowlted for by another Axis I d isorder (e.g., if dim illished sexual d esire OCClUS only in the contex t of a rvlajor Depressive Episode). However, if the distu rbance in sexual functioning antedates the Axis I disorder or is a focus of independent clinical attention, an additional diagnosis of Sexual Dysfunction can also be made. Commonly, if one Sexual Dysfun ction is present (e.g., a Sexual Arousal Disorder), additional Sexual Dysfunctions w ill also be p resent (e.g., Hypoactive Sexual Desire Disorder). In such cases, all should be d iagnosed. A Personality D iso rder may coexist wi th a Sexu aJ Dysfunction . In such cases, the Sexual Dysfunction should be recorded on Axis I and the Persona lity Disorder s hould be recorded on Axis ll lf another clinical condition, s uch as a Relation al Problem, is associated with the disturbance in sexual fWl ctioning, the Sexual Dysfunction s hould be diagnosed and the other clinical condition is also noted on Axis I. Occasional problems with sexual desire, arousa l, or orgasm that are not persistent or recurrent or are not accompan ied by marked dis tress o r interpersonal difficulty are not considered to be Sexual Dysfunctions.
302.7 1
539
302.71
Diagnostic Features
The essentia l feature of Hypoactive Sexual Desire Disorder is a d eficiency or absence of sexual fanta sies and desire for sexlJ<11 activity (Criterion A). The dishlrbance must cause marked distress or interpersonal difficulty (Criterion B). The d ysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the d irect physiological effects of a substance (including medications) or a general medical cond ition (Criterion C). Low sexual desire may be global and encompass all fomls of sexual expression or may be situa tional and limited to one p artner or to a specific sexu al acti vi ty (e.g., intercourse but not mastu rbation). There is little motivation to seek s timuli and diminis hed frus tration when deprived of the opportunity for sexual exp ression. The individua l us ually does not initiate sexual activity or may only engage in it reluctantly when it is initiated by the partner. Although the frequ ency of sexual experiences is us ually low, p ressure from the partner o r nonsexual needs (e.g., for physical comfort or intimacy) may increase the frequency of sexual encounters. Because of a lack of normative age- or genderrelated da ta on freq uency or degree of sexual desire, the diagnosis mus t rely on cl inical judgment based on the individua l's characteristics, the interpersonal detenninants, the life context, and the cultural setting. The clinician may need to assess both partllers when discrepancies in sexual desire promp t the call fo r p rofessional attention. Appa rent "low desire" in one partner may instead reflect an excessive need for sexual expression by the other partner. Alternatively, both pa rtners may have levels of desire wi thin the normal range but at different ends of the continuum.
Subtypes
Subtypes are provided to indicate onset (lifelong versus Acquired), context (Generalized versus Situational ), and etiologicaJ fa ctors (Due to Psychological Factors, Due to Combined Factors) for Hypoactive Sexual Desire Disorder. (See descriptions on p . 536.)
1 540
desire. Individuals wi th H ypoactive Sexual Des ire Disorder may have difficulties developing stable sexual rela tions hips and may have mari ta l dissatisfaction and d is ru ption.
Course
The age at onset for individuals w ith Lifelong fann s of HypoactiveSexuaJ Des ire Disorder is puberty. More frequently, the disorder develops in adulthood, after a period o f adequate sexual interest, in association with psych ological distress, stress ful life events, or interpersonal difficulties. The loss of sexual d esire may be continuou s or episodic, depending on p sychosocial or relationship factors. An episodic pattern of loss of sexual desire occurs in some individuals in relation to problems with intimacy and commitment.
Differentia l Diagnosis
Hypoactive Sexual Des ire Disorder must be distinguis hed from Sexual D ysfunction Due to a General Medical Condition. The appropria te diagnosis would be Sexual Dysfunction Due to a General Medical Condition w hen the d ysfunc tion is judged to be due exclusivel)' to the physiological effects of a speci fied general medical cond ition (see p. 558). This determination is based on his tory, laboratory finding s, or physica l examination. Certain general m edical conditions s uch as n eurological, hormonal, and metabolic abnormali ties may specificall y impair the ph}'siologica i subs trates of sexua l desire. Abnorma lities in total and bioavailable tes tos terone and prolactin may ind icate hormonal diso rders respons ible for loss of sexua l des ire. If both H ypoactive Sexual Desire Disorder and a general medical condition are p resent, bu t it is judged that the sexual dysfunction is not due exclusively to the direct physiological effects of the general medical condition, then H ypoactive Sexua l Desire Disorder, Due to Combined Factors, is diagnosed. contrast to Hypoactive Sexual Desire Disord er, a Substance-Induced Sexual Dysfun ction is judged to be due exclusively to the direct physiological effects of a substance (e.g ., antihypertens ive medication, a drug of abuse) (see p. 562). lfboth H ypoactive Sexual Desire Disorder and substance u se are present, but it is jud ged that the sexual dysfunction is not due exclusively to the direct phys iological effects of the subs tance use, then Hypoactive Sexual Desire Di sord er, Due to Combined Factors, is diagnosed. If the low sexual desire is judged to be due exclusively to the phys iological effects of both a general medical condition and s ubs tance u se, both Sexual Dysfunction Due to a General Medica I Condition and Substance-Induced Sexual Dysfun ction are diagnosed. H ypoactive Sexua l Desire Disorder may also occur in associa tion wi th other Sexu,'II Dysfunction s (e.g., Male Erectile Dysfunction). If so, both should be noted. An additional d iagnosis of Hypoactive Sexual Desire Disorder is us ually not made if the low sexuaJ desire is better accowlted for by another Axi s I disorder (e.g., Major Dep ressive Disorder, ObseSSive-Compulsive Disorder, Pos ttraumatic Stress Disorder). The additional diagnos is ma y be appropriate w hen the low desire predates the Axis I disorder or is a focus of independent clinical aHention. Occasional problems with sexu al desire that are not persis tent o r recurrent or are not accompanied by marked
302 .79
541
distress or interpersonal difficulty are not considered to be H ypoac tive Sexual Desire Disorder.
another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e .g., a drug of abuse, a medication) or a general medical condition.
Specify type:
302.79
Diagnostic Features
The essential feattue of Sexual A version Disorder is the a ve rsion to and active a voida nce of genital sexual contact w ith a sexual partner (Criterion A). The dis ttubance must cause marked dis tress or interpersonal difficulty (C riterion B). The dysfwlCtion is not better accmmted for by another Axis I d isorder (except another Sexual Dyshmctio n) (Criterion C). The individual reports anxiety, fea r, or disgust w hen confronted by a sexual opportunity with a partner. The a version to gen ital co ntact may be focused on a particular asp ect of sexual experience (e.g., genital secretions, vagina 1penetration). Som e individuals expe rience generalized revulsion to a U sexual s timuli, induding kissing and touching. The intens ity of the indjvidual's reaction w h en exposed to the avers ive s timulus may range from moderate anxiety and lack of pleasure to extreme psychological distress.
542
Su bt ypes
Subtypes are provided to indicate onset (l ifelo ng vers us Acquired), context (Gen erali zed versus Situation al), and etiologica l factors (D ue to Psychological Fac lors, Due to Comb ined Factors) for Sexua l Aversion Disorder. (See descriptions on p . 536. )
sion Disorder may experience Panic Attacks with extreme anxiety, feelings of terror, faintness, nausea, palpitations, dizziness, and breathing difficulties. There may be
markedly impaired interpersonal relations (e.g., marital dissatisfaction). Individua ls m ay avoid sexual situations or poten tial sexual partners by covert s trategies (e.g., going to sleep early, traveling, neglecting p ersonal appearance, using substances, and being overinvolved in work, social. or family activities) .
The dist urbance causes marked distress or jnterpersonal diHiculty. anot her Sexua l Dysfunction).
C. The sexual dysfunction is not better accounted for by another Axis I disorder (except
Specify type:
302 .72
543
302 .72
Diagnostic Features
The essential feature o f Female Sexual Arousal Disorder is a p ersistent or recurrent inability to attain, or to maintain lmhl completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement (Criterion A). The arou sal response consists of vasocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genita lia. 111e distUIbance must cause marked distress or interpersonal difficulty (Criterion B). The d yshmction is not better accOlmted for by another Axis r disorder (except another Sexual Dy sfunction) and is not due exclusively to the direct physiological effects of a substance (including medications) or a genal eT medical condi tion (Criterion C).
Subtypes
Subtypes are provided to indicate onset (Lifelong versus Acquired), context (Generalized vers us Situational), and etiological factors (Due to Psychological Factors, Due to Com bined Fac tors) for Female Sexual Arousal Disorder. (Sec descriptions on p.536.)
Differential Diagnosis
Female Sexual Arousal Disorder must be dis tinguished fro m a Sexual Dysfunction Due to a General Medica l Condition. 111e appropriate diagnosis would be Sexual Dysfunction Due to a General Medical Condition when the d ysfunction is judged to be due exclusively to the physiological effects of a specified general medical condition (e.g., menopausal or postmenopausal reductions in es trogen levels, atrophic vaginiti s, diabetes mellitus, radiotherapy of the pelvis) (see p . 558). Reduced lubrication has also been reported in association with lactation. This detennination is ba sed on history, laboratory fin dings, or physical examination . If both Female Sexual Arousal Disorder and a general med ical condition are present but it is judged that the sexual d ysnmction is not due exclusively to the direct physiological consequences of the general medical condi tion, then Female Sexual Arousal Disorder, Due to Combined Factors, is diagnosed. In contrast to Female Sexual Arousal Disorder, a Substance-Induced Sexual Dysfunction is judged to be due exclusively to the direct physiological effects of a sub5t.m ce (e.g ., red uced lubrication caused by antihypertensives or antihistamines) (see
544
p. 562). If both Female Sexual Arousal Disorder and substance lise are present but it
is judged that the sexual d ),sftmction is not due excl usively to the direct physio logical effects of the substance use, then Female Sexua l Arousa l Disorder, Due to Combined Factors, is diagnosed. U the arousal problems afC judged 10 be due exclusively to the physiological effects
of both a genera l medical co ndition and s ubs tance use, both Sexual Dysfunction Due to a General rvfedical Condition and Substance--Induced Sexual Dysfun ction are diag* nosed. Female Sexua l Arousal Disord e r may also occur in association w ith other Sexual Dysfunctions (e.g., Female Orgasmic Disorder). If so, both should be noted. An addi* tiona l diagnos is of Female Sexu al Arousal Diso rder is us ually not made if the sexual arousal problem is better accounted for by another Axis I disorder (e.g., Major Depressive Diso rder, ObseSSive-Compulsive Disorder, Posttraumatic Stress Disorder). The add itional diagnosis m ay be made when the p roblem w ith sexual arousal predates the Axis I disorder o r is a focus of independent clinical attention. Occasion al problems with sexual arousal that are not pers is tent or recurre nt or are not accompanied by m a rked distress or interpersonal difficulty a re not cons idered to be Female Sexual Arous al Disorder. A d jagnosis of Fem ale Sexual Arousal Disorde r is also no t appropriate if the problems in a ro usal are due to sexua l stimulation that is not adequate in focus, intens ity, and dura tion .
Persistent or recurrent inability to atta in, or to maintain until completion of the sexual activity, a n adequate lubrication-swelling response of sexual excitement.
another Sexual Dysfunction) and is not due exclusively to the direct phYSiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical cond ition .
Specify type:
302.72
302.72
Diagnostic Features
The essential feature of Male Erectile Disorder is a persistent or recurrent inability to attain, o r to maintain lmtil completion of the sexual activity, an adeq uate erection (Criterion A). The disturbance m ust cause marked dis tress or interpersonal difficulty (Criterion B). The d ysfunc tio n is not better accmmted for b y another Axis I disorder (except another Sexua l Dysfuncti on) and is not due exclus ively to the direct physiological effects of a substance (including medications) or a general medical condition (Criterion C). There are d ifferent patterns of erectile dysfwlCtion. Some individuals w ill report the inability to obtain any erection from the outset of a sexu al exp erience. Others will complain of first experiencing an adequate e rection and then losing tumescence when attempting p enetration . S till others will report that they ha ve an erection that is sufficientl y finn for penetration but that they then lose tumescence before or d uring thrustin g. Some males may report being able to experience an erection on ly during self-m asturbatio n or o n awaken ing . Masturbatory erections may be lost as well, bu t this is not common.
Subtypes
Subtypes are provided to indicate onset (Lifelong versus Acquired), context (Generalized versus Situa tional), and etiological factors (Due to Psychological Factors, Due to Combined Factors) for r-,'lale Erectile Disorder. (See descriptions on p . 536.)
Course
The various forms of Male Erectile Di sorde r follow different courses, and the age at onset varies subs tantially. The few individuals w ho have never been able to experience an erectio n of sufficient quality to complete sexual activity w ith a partner typically have a chronic, lifelong disorder. Acquired cases may remit spontaneously 15%-30% of the time. Sihlational cases may be dependent on a typ e of partner or the intensity or q uality of the relationship and are episodic and frequently recurrent.
546
Differential Di agn osi s
Male Erectile Disorder must be distinguished from Sexu al Dysfu nction Due to a General Medical Condition. The appropriate diagnosis would be Sexual Dysfun ction Due to a General Medkal Cond ition when the dysfu nction is judged to be due exclusively to the physiologica l e ffects of a s pecified general medical condition (e.g., diabetes mellitus, multiple sclerosis, renal fa il ure, p eripheral neuropathy, peripheral vascular disease, s pinal cord injury, injury of the autonomic nervous system by surgery or radiation) (see p. 558). This detennination is based on hi story (e.g., impaired ereclile functioning during masturbation), laboratory findings, or physical examination. Nocturnal penile tumescence studies can demonstrate w hether erections occur during sleep and may be helpful in differentiating primary erectile disorders from Male Erectile Disorder Due to a Genera l Medical Cond ition. Penile blood pressure, pulsewave assessments, o r duplex ultrasound srud ies can indica te vasculogenic loss of erectile functioning. Invasive procedures such as intracorporeal pharmacologica l testing or angiography can assess the presence o f arterial flow problems . Cavernosography can evaluate ven ous competence. If both Male Erectile Disorder and a general medical condition are present but it is judged that the erectile dysfunction is not due exclusively to the direct physiological effects of the general med ical condi tion, then Male Erectile Disorder, Due to Combined Factors, is diagnosed. A Su bstance-Induced Sexual Dysfu nction is d isti.nguished from Ma le Erectile Disorder by the fac t that the sexual dysfunction is judged to be due exclusively to the direct p hYSiological effects of a substance (e.g., antihypertensive medication, antidepressant medication, neuroleptic medication, a drug of abu se) (see p. 562). If both Male Erectile Disorder and substance use are present but it is judged that the erectile d ysfu nction is not due exclusively to the d irect physiological effects of the substance use, then Male Erectile Disorder, Due to Combined Factors, is diagnosed . If the arousal problems are judged to be due exclusively to the physiological effects of both a general medical condition and substance use, both Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction are diagnosed. Male Erectile Disorder may also occur in associ ation with other Sexual Dysfunctions (e.g., Premarure Ejaculation).lf so, both should be noted. An additiona l diagnosis of Male Erectile Disorder is usually not mad e if the erectile dysfun ction is better accounted for by another Axis I disord er (e.g., Major Depressive Disorder, Obsessive-Compulsive Disorder). The additional diagnosis may be made when the erectile d ysfunction predates the Axis I d isorder or is a focus of indep end ent clinical attention. Occasion al p roblem s w ith having erec tion s that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty are not considered to be Male Erectile Disorder. A diagnosis of Male &ectile Disorder is also not appropriate if the erectile dysfunction is due to sexual stimulation that is not adequate in focus, intensity, and duration. Older males may require more stimulation or take longer to achieve a fu ll erection. TIlese physiological changes sh ould not be considered to be Male Erectile Disord er.
547 1
C. The erectile dysfunction is not better accounted for by another Axis I disorder (other
than a Sexual Dysfunction) and is not due exclusively t o t he direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a genera l medical condition.
S pecify type:
Orgasmic Disorders
302.73 Female Orgasmic Disorder (formerly Inhibited Female Orgasm)
Diag nostic Featu res
The essential feature of Female Orgas mic Disorder is a pe rsis tent or recurre nt delay in, or absence of, orgas m folloW ing a norma l sexual excite ment phase (Criterion A). Women exhibit wide variability in the ty pe or intensity of stimu lation that triggers orgasm. The diagnos is of Female O rgasmic Disorder should be based on the clinicia n' s jud gment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation s he receives. The disturbance must cause marked distress or interpersonal difficulty (Criterion B). The dysfun ction is not better accOlmted fo r by another Axis I d isorder (except another Sexua l Dysfunction ) and is not due exclusively to the direct physiological effects of a substance (including medications) or a ge neral medical cond ition (Criterion C).
Subtypes
Subtyp es are provided to indicate onset (Lifelong versus Acquired ), context (Generalized versus Situ ati onal), and etiological fac tors (Due to Psychol og ica l Factors,
1 548
Due to Combined Factors) for Female Orgasmic Disorder. (See descr iptions on p.536.)
Course
Beca use orgasmic capacity in females may increase with increasing sexual experience, Female Orgasmic Disorder may be more prevalent in younger women . Most female orgasmic disorders are life long ra ther than acquired. Once a female learns how to reach orgasm, it is uncom mon fo r her to lose that capacity, un less poor sexual communication, rela tionship conflict, a tra umatic experience (e.g., rape), a Mood Disorder, or a general med ical condition intervenes. When org.1smic d ysfunction occurs only in certain situations, difficulty w ith sexual desire and arousal are often present in addition to the orgasmic disorder. Many fema les increase their orgasmic capacity as they experience a w ider variety of stimulation and acquire more knowledge about their own bodies.
Differential Diagn os is
Female Orgasmic Disorder must be distinguished from a Sexual D ysfunction Due to a General Medical Condition. The appropriate d iagnosis would be Sexual Dysfunction Due to a General Medical Cond ition when the d ysflU1ction is judged to be due exclusively to the ph ysiolog ical effects of a specified general medical condition (e.g., spinal cord lesion) (see p. 558) . This d etermination is based on history, laboratory find ings, or physical ex.1mination . If both Female Orgasmic Disorder and a gener.1! medica l condition are present but it is judged that the sexua l dysfunction is not due exclusively to the d irect physiological effects of the genera l medic.ll condition, then Female Orgasmic Disorder, Due to Combin ed Factors, is diagnosed . In contrast to Female Orgasmic Disorder, a Substance-Induced Sexual Dysfunction is jud ged to be d ue exclusively to the direct ph ysiological effects of a substance (e.g., antidepressants, benzodiazepines, netuoieptics, antihypertensives, opioids) (see p. 562). If both Female Orgasmic Disorder and substance use are p resent but it is judged that the sexual dyshmction is not d ue. exclusively to the direct physiological effects of the substance use, then Femal e Orgasmic Disorder, Due to Combined Factors, is diagnosed. If the sexua l dysfunction is judged to be due exclusively to the physiological effects
302.73 Fema le Orgasm ic Disorder (formerly Inhibited Fema le Orgasm) of both a general m ed ical condition and substance use, both Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction are diagnosed. Female Orgasmic Diso rder may also occur in association with other Sexual Dysfunctions (e.g., Fema le Sexual Arous al Disorder). If 50, both should be noted. An additional diagnos is of Female Orgasm ic Disorder is usually n ot m ade if the orgasmic difficulty is better accounted for by a n othe r Axis I di sorder (e.g., Major Depressive Disorde r). This additional diag nos is may be made when the orgasmic difficulty predates the Axis I disorder o r is a focu s of independent clinical attention. Occasional orgasm ic p roblems tha t are not persis tent o r recurrent or a rc not accompanied by marked distress o r interpersonal difficulty are not cons ide red to be Female OrgasmiC Disorder. A diagnosis of Female O rgasmic Disorder is als o not appropria te if the problems a re due to sexual s tinlU lation tha t is not adequate in focu s, intens ity, and d uration.
C. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfuncti on) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a genera l medical condition.
Specify type:
Genera lized Type Situational Type Specify: Due to Psychological Factors Due to Combined Factors
sso
The d isturbance must cause marked distress or interpersonal difficulty (Criterion B). The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction ) and is not due exclusively to the direct physiological effects of a s ubs tance (including medications) or a general medical condition (Crite rion C) . In the most common form of Male Orgasmic Disorder, a male cannot reach orgasm during intercourse, although he can ejaculate from a partner's manual or oral s timulation. Some males with Male Orgasmic Disorder can reach coital orgasm but only after very p rolonged and intense noncoital stimula tion . Some can ejacu late only from masturbation. An even smaller subg roup have experienced orgasm only at the moment of waking from an erotic dream.
Subtypes
Subtypes are provided to indicate onse t (Lifel ong versu s Acquired), context (Generalized versus Situational), and etiological factors (Due to Psychological Fa ctors, Due to Combined Factors) for Male Orgasmic Disorder. (See descriptions on p. 536.)
Differential Diagnosis
Male O rgasmic Disorder must be dis tinguished from a Sexual Dysfunction Due to a General Medical Conditi on . The approp riate diagnosis would be Sexual Dysfunction Due to a General Medical Condition when the d ysfunction is judged to be due exclusively to the phys iological effects of a specified general medical condition {e.g.,
302.74
hyperprolactinemia) (see p. 558). This detennination is based on history. laboratory findings, or physical examination . Sensory threshold testing may demonstrate reduced sensation in the skin on the penis that is due to a neurological condition (e.g . spinal cord injuries, sensory neuropathies) . If both Male Orgasmic Disorder and a general medical cond ition are present but it is judged that the sexual d ysfunction is not due exclusively to the direct physiological effects o f the general medical condition, then tvfale Orgasmic Disorder, Due to Combined Factors, is diagnosed. In contrast to Male O rgasmic Disorder, a Substance-Induced Sexual Dysfunction is judged 10 be due exclusively to the direct physiological effects of a substance (e.g., alcohol, opioid s, antihypertensives, antidepressants, neuroleptics) (see p. 562). Uboth Male Orgasmic Disorder and substance use are present but it is judged that the sexual dysfunction is not due exclUSively to the direct physiological effects of the substance use, then Male Orgasmic Disorder, Due to Combined Factors, is diagnosed . If the orgasmic d ysfunction is judged to be due exclusively to the ph ysiological effeds of both a general medical cond ition and substance use, both Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfun ction are diagnosed. Male Orgasmic Disorder may also occur in association with other Sexual Dysfunctions (e.g., Male Erectile Di sorder). U so, both should be noted. An additional diagnosis of Male Orgasmic Disorder is usually not made if the orgasmic difficulty is better aCCDlmted for by another Axis I disorder (e.g., Major Depressive Disord er). An additional d iagnosis may be made when the orgasmic difficulty preda tes the Axis I disorder or is a focll s o f independen t clinical attention . Several ty pes of Sexual Dysfunction (e.g., ejaculation but without pleasurable orgas m, orgasm that occurs w ithout ejacu lation of semen or with seepage of semen rather than propulsive ejaculation) wou ld be diagnosed as Sexu al Dysfunction Not Othen."ise Specified rather than as Ma le Orgasmic Disorder. Occasion al orgasmic problems that are not persistent or recurren t or are not accompanied by marked distress o r interpersonal difficulty are not considered to be Male Orgasmic Disorder. As males age, they may require a longer period of stimulation to achieve o rgasm. The clinician mllst also ascertain that there has been suffi cient stimulation to attain orgasm.
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Persiste nt or recurrent delay in, or absence of, orgasm following a norma l sexual excitement phase during sexua l activity t hat the clinician. taking into account the person's age, judges to be adequate in focus, intensity. and duration.
cal effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Specify type:
Life long Type Acquired Type
Specify type:
30 2.75
Diagnostic Features
The essential fea ture of Premature Ejaculation is the persistent or recurre nt onset of orgasm and ejaculation w ith minimal sexual stimulation before, on, or shortly a fl er penetration and before the person w ishes it (Criterion A). The clinician must take into account factors that affect duration of the e xcitemen t phase, such ,lS age, novelty of the sexual partner o r sihtation, and recent freq uency o f se xual activity. The majority of males with this disorder can delay orgasm during self-masturbation for a considerably longer time than during coitus. Partners' estimates of the duratio n of time from the beginning of sexual activity until ejacula tion as well as their judgment of w he ther Premature Ejacula tion is a problem can be quite d ispa rate. The disturbance mus t cause m arked distress or interpersonal difficulty (Cr iterion B). The p remature ejaculation is not due excl usi vel y to the direct effects of a s ubstance (e.g., wi thdrawal from opioids) (Criterion C).
302.75
Premature Ejaculation
Subtypes
Subtypes are p rovided to in dica te onset (Lifelong versus Acquired), context (Generalized versus Situational), and etiological factors (Due to Psychological Factors, Due to Combined Factors) for Premature Ejaculation. (See descriptions on p . 536.)
Course
A majority of young males learn to d elay orgasm with sexual experience and aging, but some continue to ejaculate prematurely and may seek help for the disorder. Some males are able to delay ejaculation in a long-term relationship but experience a recurrence of Premature Ejaculation when they have a new partner. Typically, Premature Ejaculation is seen in yOWlg men and is present from their firs t attemp ts at intercourse. However, some males lose the ability to delay orgasm after a period of adequate fun ction. When onset occurs after a period of adequate sexual func tion, the context is often a d ecreased frequency of sexual activity, intense performance an...,iety with a n ew partner, or loss of ejaculatory control related to difficulty achieving or maintaining erections. Some males who have stopped regu lar use of alcohol may develop Premature Ejaculation because they relied on their drinking to delay orgasm instead of learning behavioral strategies.
Differential Diagnosis
Premature Ejacula tion should be distinguished from erectile d ysfuncti on related to the development of a general m edical condition (see p. 558). Some individuals with erectile dyshmction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimu lation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or a re not accom panied by marked distress or interpersonal d ifficulty do not qualify for the diagnosis of Premature Ejaculation. The clinician should also take into account the individual's age, overall sexual exp erience, recent sexual activity, and the novelty of the partner. When problems with Premature Ejaculation are due exclUSively to substance use (e.g., Opioid Withdrawal). a SubstanceInduced Sexual Dysfunction can be d iagnosed (see p. 562).
554
Lifelong Type
Acquired Type
Specify type:
Sexual Pain Disorders 302.76 Dyspareunia (Not Due to a General Medical Condition)
Diagnostic Features
The essential feature of Dysparelmia is gen ital pain tha t is associa ted w ith sexual intercourse (Criterion A). A lthough it is most" commonly experienced during coitus, it may also occur before or after intercourse. The d isorder can occur in both males and females. In females, the pain may be desc ribed as s uperficial during intromission or as deep during p enile th rusting. The intensity of the symptoms may range from mild discomfort to s harp pain. Thedisturhance must cause marked distress or interpersonal difficulty (Crite rion B). The disturbance is not caused exclusively by Vaginismus or lack of lubrica tion , is not better accoun ted for by another Axis I disorder (except for another Sexual Dys functio n), and is not d ue exclusively to the direct physiological effee ts of a subs tance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion C).
555
Subt ypes
Subtypes are provided to indicate onset (Lifelong versu s Acq uired ), context (Generalized versus Situational), and etiological factors (Due to Psych ological Factors, Due to Com b in ed Factors) for Dyspareunia. (See descriptions on p. 536.)
Cou rse
The limited amount of information available suggests that the course of Dyspareunia tends to be chronic.
Disorder). The additional diagnosis may be made w hen the orgasmic difficulty predates the Axis I disorder or is a focus of independent clinical attention. Dyspareunia can also occur in association w ith other Sexual Dysfunctions (except Vaginismus), and if criteria for both are met, both should be coded. Occasional p ain associated w ith sexu al intercou rse tha t is not persistent or recurrent or is not accompanied by marked d istress or interpersonal d ifficul ty is not consid ered to be Dyspareunia.
Recurrent or persistent genital pain associated with sexual intercourse in eit her a male or a female.
better accounted for by another Axis I disorder (except another Sexua l Dysfunction), and is not due exclusively to the direct physiological effects of a substance (e .g., a drug of abuse, a medication) or a genera l medical condition.
Specify type:
306.51
Subty pes
Subtypes are provided to indicate onset (Life long versus Acq uired), contex t (Generalized versus Situation al), and etiological fac tors (Due to Psych ological Factors, Due to Combined Factors) for Vaginismus. (See descriptions on p. 536.)
Course
Lifelong Vaginismus usually has an abrupt onset, first manifest during initial attempts at sexual penetration by a partner or during the fi rst gynecological exam ination. Once the disorder is established, the course is usually chronic unless ameliorated by treatment. Acquired Vaginismus also may occur suddenly m response to a sexual trauma or a general medical condition .
Differenti al Di ag nosis
Vaginismus must be d istinguished from a Sexual Dys fun ction Due to a General Medical Condi tion (see p. 558). The appropriate diagnosis would be Sexual Dysfunction Due to a General Medical Condition when the dysfunction is judged to be due exclUSively to the physiological effects of a s pecified general medical condition (e.g., endometriosis or vaginal infection). This determination is based on history, laboratory findings, o r physical examination. Vaginismus may remain as a residual problem after resolution of the general medical condition. If both Vaginismus and a general medical condition are p resent but it is judged that the vaginal spasms are not due exclusively to the direct physiological effects of the general medical condition, a diagnosis of Vaginismus, Due to Combined Factors, is made. Vaginismus may also occur in association with other Sexual Dysfunctions (e.g., Hypoactive Sexual Desire Disorder). If so, both should be noted. Although pain associated with sexual in tercourse may occur with Vaginismus, an additional diagnosis of Dyspareu nia is not given. An additional diagnosis of Vaginismus is usually not made if the vaginal spasms are better accounted for by an other Axis I condi ti on (e.g., Somatization Disorder). TIle additional diagnosis may be made when the vagina l spasms p redate the Axis I di sorder or are a focus of independent clinica l attention.
558
the vagina that interferes with sexual intercourse. B. The dist urbance causes marked distress or inte rpersonal difficulty.
C. The disturbance is not better accounted fo r by another Axis I disorder (e.g ., Somati zat ion Disorder) and is not due exclusively to the direct physio logical effects of a gen eral medical cond ition.
Specify type:
559
logical. several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and that of the sexual d ysfunction. A second consideration is the presence of features that are atypical of a primary Sexual Dysfunction (e.g., atypical age at onset or course). Evidence from the literature that suggests that there can be a direct association between the general medical condition in question and the d evelopment of the sexual dysfunction can provide a useful context in the assessment of a particular situation. In addition, the clinician must also judge that the disturbance is not better accOlmted for by a primary Sexual Dyshmction, a Substance-Induced Sexual Dysfunction, or anoUler primary mental disorder (e.g., Major Depressive Disorder). These determinations are explained in greater detail in the "Mental Disorders Due to a General Medical Condition" section (p. 181). In contrast, a Sexual Dysfunction diagnosis with the subtype "Due to Combined Factors" is made if a combination of psychological factors and either a general medical condition or a substance is judged to have an etiological role, but no one etiology is sufficient to accOlmt for the dysfunction.
Subtypes
The diagnostic code and tenn for a Sexual Dysfuncti on Due to a General Medical Condition is selected based on the predominant Sexual Dysfuncti on. The tenns listed below should be used instead of the overall rubric "Sexual Dysfullction Due to a General Medica l Condition." Fem ale Hypoactive Sexual Desire Disorder Due to ... [Indicate HIe Gelleral Medical Conditioll). This term is used if, in a female, deficient or absent sexual desire is the predominant feature. 608.89 Male Hypoaclive Sexua l Desire Disorder Du e to ... [Illdicate tile Gelleral Medical CO llditioll}. This term is used if, in a male, d eficient or absent sexual desire is the predOminant feature. 607.84 Male Erectil e Disorder Due to ... [Indicate tile General Metiical Conditiold. TIus term is used if male erectile dyshmction is the predominant feature. 625.0 Female D yspareunia Due to ... [Illdica te tile Gellera l Medical C01/ditioIlJ. This term is used if, in a female, pain associated with intercourse is the predominant feature. 608.89 Male Dyspareunia Due to ... [Illdicate t1,e Ge/leral Medical CO/ltii tiollJ. 111is term is used if, in a male, pain associated with intercou rse is the predominant feature. 625.8 Other Fem ale Sexual Dysfunction Due to .. . !IlIdicate ti,e General Medica l COlltiitiollJ. This term is used if, in a female, some other feature is predominant (e.g., Orgasnuc Disorder) or no feature predominates. 608.89 Other Male Sexual Dysfunction Due to ... [Illdicate ti,e Gelleral Medica l Condition). This term is used if, in a male, some other fea ture is predominant (e.g., OrgasmiC Disorder) or no feature predominates. 625.8
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Recording Proce dures
tion, the clinician should note both the specific phenomenology of the d ysfunction (from the tis t above) and the identified general medical condition judged to be causing the dysfunction on Axis I (e.g., 607.84 Male Erectile Disorder Due to Diabetes Mellitus). The ICD-9-CM code for the general medical condition is also noted on Axis III (e.g., 250.0 diabetes mellitus). (See Appendix G for a list of selected ICD-9-CM diagnos tic codes for general medical conditions.)
use may be especially indicative of a Substance-Induced Sexual Dysfun ction, depending on the type or amo unt of the substance used or the d uration of use. If the cl inician has ascertained that the sexual d ysfunction is due to both a general med ical condition and substance use, both diagnoses (Le., Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction) can be given. Hypoactive sexual desire, arousal d ysfun ction, and, to a lesser exten t, orgasmic dysfun ction can also occur as sympto ms of Major Depress ive Disorder. In Major Depressive Disorder, no specifi c and d irect causative pa thoph ysiological mechanisms associ ated with a genera l med ical condition can be demonstrated . Sexual Dysh mction Due to a General tvled ical Condition must be distinguished from the dimini shed sexual in terest and fun ctioning that may acco mpan y ag ing.
Diagnostic criteria for Sexual Dysfunction Due to [Indicate the General Medical Condition]
al difficulty predominates in t he cl inical picture.
A. Ctinica lly significant sexual dysfuncti on that re sults in marked distress or interp erson-
B. There is evidence f rom the history, physical examination, o r laboratory f i nd ings that t he sexual dysfunct ion is fully explained by the direct physio logical effects of a general medica l con dition.
C. The dist urbance is not better accounted for by another ment al disorder (e.g., Major Depressive Disorder).
Select code and term based on the pre dominant sexua l dysfunct ion:
625.8 Female Hypoactive Sex ual Desire Disorder Due to .. , [Indicate the General Medical Condition}: if deficient or absent sexual desi re is the predominant featu re 60B .B9 Male Hypoactive Sexual Desire Disorder Due to ... [Indicate the General Medical Condition}: if deficient or absent sexua l desire is the predominant fe ature 607.84 Male Erectile Disorder Due to .. [Indicate the General M e dical Condition}: if ma le erectile dysfunction is t he predominant feature 625 .0 Female Dyspareunia Due to . . . [Indicate th e General Medical Condition}: if pa in associated w ith intercourse is the predom inant feature 60B.B9 Male Dyspareunia Due to [Indicate the General Medical Condition}: if pain associated with i ntercourse is the predominant feature 625 .B Other Female Sexual Dysfunction Due to . .. [Indicate the General Medical Condition}: if some other feature is predominant (e.g., Orgasmic Disorder) or no fea t ur e predomina t es 60B.B9 Other Male Sexual Dysfunction Due to ... [Indicate the General Medical Condition}: if some other feat ure is predominant (e.g., Orgasmic Disorder) or no featur e predominates Coding note: Include the name of the general medical condit ion on Axis t e.g., 607 .84 Male Erectile Disorder Due to Diabetes Mellit us; also code the general medical condit ion on Axis III (see Appendix G for codes).
1 562
paired desire, impaired arousal. impaired orgasm, or sexual pain. The d ysfunction is judged to be fully explained by the direct physiological effects of a substance (i.e., a
drug of abuse, a m edication, or toxin exposure) (Criterion B). The dis turbance must not be be tter accounted for by a Sexual Dysfunction that is not s ubs tance induced (Criterion C). This diagnosis shou ld be made instead of a diagnosis of Substance Intoxication only when the sexual symptoms are in excess of those usually associated with the intoxication syndrome and when the symptoms are suffidentl y severe to warrant independent clinical attention. For a more detailed d iscussion of SubstanceRelated Disorders, see p. ]91. A Substance-Induced Sexual DysfWlction is distinguished from a primary Sexual Dysfunction by considering onset and course. For drugs of abuse, there must be evidence o f intoxication from the history, phYSical examination, or laboratory findings. Substance-Induced Sex ua l Dysfunctions arise on ly in association with intoxication, whereas primary Sexua l DysfWlcti ons may precede the onset of substance use or occur during times of sustained abstinence from the substance. Factors suggesting that the d}'sfunction is better accounted for by a primary Sexual Dysfunction include persistence of the d ysfunction for a substantial period of time (i .e., a m on th or more) after the end of Substance In toxication; the development of a dysfunction that is s ubstantially in excess of what would be expected given the type or amoWlt of the substance used or the duration of use; or a history of prior recurrent primary Sexual Dysfunctions.
Specifiers
The following specifiers for Substance-Induced Sexual Dysfunction are selected based on the predominant sexual dysfunction. Although the clinical presentation of the sexual dyshmction may resemble one of the specific primary Sexual Dysfunctions, the full criteria for one of these disorders need not be m et. With Impaired Desire. Thi s specifier is used if deficient or absent sexual desire is the predo minant feature . With Impaired Arous al . This specifier is used if impa ired sexual arousal (e.g., erectile d ys function, impaired lubrication) is the pred ominant fealme. With Impaired Orgasm . This s pecifier is lIsed if impaired o rgasm is the predominant fearnre. With Sexual Pain. This specifier is u sed if pain associated with intercourse is the predominant feature. Substance-Induced Sexual Dys functions usua lly have thei r onset during Substance Intoxication, and this may be indicated by no ting With Onse l During In toxication .
563 1
Proce du res
The name of the Substance-Induced Sexual Dysfunction begins with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the sexual dysfunction. The diagnostic code is selected from the Listing of classes of substances provided in the criteria set. For substances that do not fit into any o f the classes (e.g., f] uoxetine), the code for "Other Substance" should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by Lis ting the appropriate E-code on Axis I (see Appendix G). The name of the disorder is foUowed by the specification of predominant symptom presentation (e.g., 292.89 CocaineInduced Sexual D}'sfunc tion, With Impaired Arousal). When more than one substance is judged to play a significant role in the development of the sexual d ysfunction, each should be listed separately (e.g., 291.89 Alcohol-Induced Sexual Dysfun ction, With Impaired Arousal; 292.89 F1uoxetine-Induced Sexual Dysfunction , With Impaired Orgasm). If a substance is judged to be the etiological facto r, but the specific substance or class o f substances is unknown, the category 292.89 Unknown Substance-Induced Sexual Dysfunction may be used.
Specific Substances
Sexual Dysfun ctions can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cocaine; opioids; sedatives, hypnotics, and anxiolytics; and other or unknow n substances. Acu te intoxication with or chronic Abuse of or Dependence on substances of abuse has been reported to d ecrease sexual interest and cause arousal problems in both sexes. A decrease in sexual interest, arousal disorders, and orgasmic disorders may also be caused by prescribed medications in cluding antihypertensives, histamine H2 receptor antagonists, antidepressants (especially selective serotonin reuptake inhibitors), neuroleptics, anxiolytics, anabolic steroids, and antiepileptics. Painful orgasm has been reported with fluphenazine, thioridazine, and amoxapine. Priapism has been reported with use of chlorpromazine, trazodone, and d ozapine and following penile injections of papaverine or prostaglandin. Medications such as antihypertensive agents or anaboUc steroids m ,,)' also promote depressed or irritable mood in addition to the sexual d ysfunc tion, and an additional d iagnosis of Substance-Induced Mood Disorder may be warranted. Current clinical experience strongly su ggests that Substance-Induced Sexual Dysfuncilon \5 usually generalized (i.e., not limited to certain types of stimulation, situations, or partners).
564
exacerbation, or maintenance of a sexual dysfunction, the diagnosis is the primary Sexual Dysftmction (with the subtype Due to Combined Factors). A Su bstan ce-Induced Sexual Dysfunction is dis tinguished from a primary Sexual D ys function by the fac t that the symptoms are jud ged to be fully explained by the direct effects of a subs tance (see p . 562) . A Substance-Induced Sexual Dysfunction due to a prescribed treatment for a mental disorder or general medical condition must ha ve its onset while the person is receiving the medication (e.g ., antihypertensive medication). Once the iTeatmen l is discontinued, the sexual dysflmction w ill remit wi thin days to several weeks (depending on the half-life of the substance). If the sexual d ysfunction persis ts, other causes for the d ysfwlCtion should be considered . Side effects of prescribed medications that affect sexual fu nction may lead individuals to be noncompliant with the medication regimen if they value sexual performance over the benefits of the medication. Because individuals with general medica l conditions often ta ke medications fo r those conditions, the clinician must consider the possibil ity that the sexual d yshmction is ca used by the physiological consequences of the general medical condition rather than the medication, in which case Sexual D ys functio n Due to a Gen eral Medical Condition is diagnosed. The history often provides the primary basis for sllch a judgment. At times, a change in the treahnen t for the general medical condition (e.g., medication s ubstitution or discontinuation) may be needed to determine empirically for tha t person wh ether the medication is the causative agent. if the clinician has ascertained that the d ysfunction is due to both a general medic.)l condition and substance use, both diagnoses (i.e., Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexu al Dysfunction) are given. \o\'hen there is insufficient evidence to determine whether the Sexual Dysfunction is due to a substance (including a medication) or to a general medical condition or is primary (i.e., not due to either a substance or a general medical condition), Sexual D ysfunction Not Othen... ise Specified would be indicated.
302 .70
565
Intoxicat ion (2) medi cation use is etiologically related to the distur bance
C. The distu rbance is not better accounted for by a Sexual Dysfunction that is not subst ance induced. Evidence that the symptoms a re better accounted for by a Sexual Dysfunction that is not substance induced might include the following: the sympto ms p recede the o nset of the substance use o r dependence (or medication use); the symptoms persist for a subst antia l period of time (e.g . about a month) after the cessation of intoxication, or are su bstantia lly in excess of what would be expected g iven the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Sexual Dysfunction (e.g., a history of recurren t non-substance-related episodes) .
Note: This diagnosis shou ld be made instead of a diagnosis of Substance Intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxica tion syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.
Code [Specifi c Substance]- Induced Sexual Dysfunction:
(29 1.89 Alcohol; 292 .89 Amphetamine [or Amphetamine-like Sub!>tance]; 292.89 Cocaine; 292 .89 Opioid; 292 .89 Sedative. Hypnotic. or Anxiolytic; 292.89 Other [or Unknown) Sub!>tance)
Specify if:
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
566
1. No (or s ubstantially d iminished) subjective erotic fee lings despite otherwisenormal arousal and orgasm 2. Situations in which the clinician has concluded tha t a sexual dysfunction is presen t but is unable to determine whether it is p rimary, due to a general medical condition, or substance induced
Paraphilias
Di agnosti c Features
The essential features of a Paraphilia are recurren t, intense sexu ally arousing fantasies, sexual urges, or behaviors generally involving 1) n onhuman objects, 2) the suffering or h umiliation of oneself or one's par tner, or 3) children or other nonconsenting persons tila! occur over a per iod of at least 6 months (Cr iterion A) . For some individuals, paraphilic fanta sies or s tim uli are obligatory for erotic arousal and are always included in sexual activity. In other cases, the paraphilic preferences occur only episodic.1l1y (e.g ., perhaps during per iods of stress), whereas at other times the person is a ble to fu nction sexually without paraphilic fantas ies or stimuli. For Pedophi lia, Voyeurism, Exhibitionism, and Frotteurism, the d iagnosis is made if the person has acted on these urges or the urges or sexu al fantas ies cause marked d is tress or inte rpersonal d ifficu lty. For Sexual Sadism, the diagnosis is made if the person has acted on these LUges with a nonconsen ting person or the urges, sexu al fan tasies, or beh aviors cause mar ked distress or interpersonal d ifficu lty. For the re main ing Paraphilias, the diag nosis is made if the behavior, sexu al u rges, or fa ntasies cause clinically significant distress or impairment in social, occupational, or other im portant areas of ftmctioning (Cri terion B). Paraphilic imagery may be acted out w ith a nonconsenting partner in a way tha t may be injurious to the partner (as in Sexual Sadism or Pedop hilia) . The in d ividual may be subject to arrest and incarcera tion. Sexu al offenses against ch ild ren constitute a significant proportion of all rep orted criminal sex acts, and ind ividuals with Exhibitionism, Pedophilia, and Voye urism make up the majority of app rehended sex offenders. In some situations, acting ou t the parap hilic imagery may lead to self-injury (as in Sexua l Masochism). Social and sexual relationships m ay suffer if others find tht unusual sexual behavior shameful or repugnant or if the individ ual's sexu al partne] refuses to cooperate in the u nusual sexual p references. In some instances, the unusuai behavio r (e.g., exhibitionistic acts or the collection of fetish obje<ts) may become the major sexual activi ty in the individual 's We. These individua ls a re rarely self-referred a nd usually come to the attention of mental h ealth p rofessionals only when their behavior has brought them into conflict with sexu al par tners or society. TIle Paraphilias described here are conditions that have been specifically identified by previous classifications. They include Exhibitionism (exposu re of genitals), Fetish ism (use of nonliving objects), Frotteurism (touching and rubbing against a noneonsenting person), Pedophilia (focus on pre pubescent children), Sexual Masochism (receiving hum iliation or suffe ring), Sexual Sadism (inflicting hu miliation or suffer
Para p h il ias ing), Transvestic Fetishism (cross-dressing), and Voyeurism (obsen' ing sexual activity). A residual category, Paraphilia Not Otherwise Specified, includes other Pa raphilias tha t are less frequently e ncountered. Not uncommon ly, individuals have more than one Paraphilia.
568
Prevalence
Although Pa.raphilias are rarel), diagnosed in genera l dinical facilities, the large commercial market in paraphllic pornog raphy and paraphemalia suggests that its prevalence in the community is likely to be higher. The most common presenting problems in clinics that s pecialize in the treatment of Paraphilias are Pedophilia, Voyeurism, and Exhibitionis m. Sexual Masochism and Sexual Sad ism are much less commonly seen. Approximately one-haH of the individuals with ParaphiJias seen clinically are married.
(ourse
Certain of the fanta sies and behaviors associated with Paraphilias may begin in childhood or early ado lescence but become better defined and elaborated during adolescence and early adulthood. Elaboration and rev ision of paraphilic fanta sies may continue over the lifetime of the individual By definition, the fantasies and urges associated with these disorders are recurrent. Many individuals report that the fantasies are always present but that there are period s of time when the frequ ency of the fanta sies and intensity of the urges vary subs tantia lly. The disorders tend to be chronic and lifelong, but both the fantasies and the behaviors often diminish with advancing age in adults. The behaviors may increase in response to p sychosocial s tressors, in rela!"ion to other mental di sorders, or w ith increa sed oppo rtunity to engage in the Paraphi lia .
Differential Diagnosis
A Paraphilia must be dis ting uished from the non path ological u se of sexual fan tasies, beh aviors, or objects as a stim ulus fo r sexual excitem ent in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to clinica lly Significan t distress o r impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complica!"ions, interfere with social relationships). In Men tal Retardation, Dem entia, Personality Chan ge Du e to a Gen eral Medical Con d iti on, Su bstance Intox ication, a Man ic Episod e, or Schizophrenia, there may be a decrease in judgment, social skills, or impulse control that, in rare instances, leads to unusual sexual behavior. This can be distinguished from a Paraphilia by the fa ct that the unus ual sexual behavior is not the individual's preferred or obligato ry pattern, the sexual symptoms occur exclUSively du ri.ng the course of these mental d isorders, and the unusual sexua l acts tend to be isolated rather than recurrent and usually have a later age at onset.
302 .4
Exhi bitio ni sm
Th e individ ual Paraphi lias ca~ be d istinguished based on differences in the characteristic paraphilic focus. However, if the individ ual's sexual preferences meet criteria for marc than one Paraphilia, all can be diagnosed . Exhibitionis m must be distinguished from pub lic urination, which is sometimes offered as an explanation fo r the behavior. Fetishism and Tran sves tic Fetishism both often involve articles of feminine clothing. In Fetishism, the focus of sexual arousal is on the article of clothin g itself (e.g ., pan ties), whereas in Transvestic Fetishism the sexual arousal comes from the act of cross-dressing. Cross-dressing, which is present in Transvestic Feti s hi sm, may also be present in Sexual Masochism . In Sexu al Masochism, it is the humiliation of being forced to cross-dress, not the garments themselves, that is sexually exciting. Cross-dressing may be associated with gender d ysphoria. If some gen der dysphoria is present b u t the full criteria for Gender Identity Disorder are not met, the diagnosis is Tran sves tic Feti s his m, W ith Gender D ysphori a. Individ uals should recei\'e the additional diagnosis of G ender Identi ty Disord er if their presentation meets the full criteria for Gender Identity Disorder.
302.4
Exhibitionism
The paraphilic focus in Exhibitionism involves the exposure of one's genita ls to a stranger. Sometimes the indiv idual mashuba tes while exp osing himself (or while fantasizing exposing himself). If the person acts on these urges, there is generally no attempt at fmther sexual activity with the stranger. In some cases, the individual is aware of a desire to surprise or shock the observer. In other cases, the individual has the sexually arousing fanta sy that the observer w ill become sexually aroused . The onset usually occurs before age 18 years, although it can beg in at a later age. Few arrests are made in the o lder age groups, w hich may s uggest tha t the condition becomes less severe after age 40 years.
302.81
Fetis hi s m
The paraphilic focus in Fetis hism involves the use of nonliving objects (the "fetish"). Among the more common fetish objects are women's UJlderpants, bras, stockings, shoes, boots, or other wearing appa rel. nle person w ith Fetishism frequentl y mashlrbates while holding, rubbing, or smelling the fetish object or may ask the sexual partner to wear the object during their sexual encOlmters. Usually the fetish is required or strongly preferred for sexual excitement, and in its absence there may be erectile d ys-
1 570
function in males. This Paraphilia is not diagnosed when the fetishe s are limited to articles of female clothing used in cross-d ressing. as in Transvestic Fetishism, or when the object is genitally stimulating because it has been designed for that purpose (e.g., a vibrator). Us ually the Para philia begins by adolescence, although the fetis h may h ave been endowed with s pecial significance earlier in childhood . O nce established, Fetishis m tends to be chronic.
8. The fa ntasies, sexual urges, or behaviors cause clinically significant distress or impairment in socia l, occupational, or other important areas of functioning.
C. The fetish o bjects are not limited to articles of fema le clothing used in crossd ressing (as in Transvestic Fetishism) or devices designed for the purpose of tactile genital stimu lation (e.g ., a vibrator).
302.89
Frotteurism
The paraphilic foc us of Frotteurism involves touching and rubbing against a nonconsenting person. The behavior us ually occurs in crowded p laces from w hich the ind ividual can more easily escape arres t (e.g ., on busy sidewalks o r in public transportation vehicles) . He rubs his genitals against the victim's thighs and buttocks or fondles her genitalia or breas ts with his hands. \o\'"hile doing this he us ually fanta s izes an exclusive, caring relationship w ith the victim . H owever, he recognizes that to avoid possible p rosecution, he mu st escape detection after touching his victim. Usually the para philia begins by adolescence. Most acts o f fro ttage occur w hen the person is ages 15-25 years, after w hich there is a gradual decline in frequency .
ual urges, o r behaviors involving touching and rubbing against a nonconsenting per son. B. The perso n has acted on t hese sexual urges, o r the sexual urges or fa ntasies cause marked distress or interpersonal diHiculty .
302.2
Ped ophilia
571
302.2
Pedophilia
The ptlraphilic focu s of Pedophilia involves sexual activity wi th a prepubescent child (genera lly age 13 years or younger). The individual with Pedophilia mus t be age 16 yeMs or o lder and a t least 5 years older than the child. For individuals in late adolescence with Pedophilia, no precise age difference is speci fi ed , and cl inical judgment mus t be used ; both the sexual mahlrity of the dilld and the age difference must be taken into account. Individuals with Pedophilia generally report an attraction to children of a particular age range. Some ind ividuals prefer males, others females, and some are aroused by both males and females. Those attracted to females usually prefer 8- to 100rear-olds, whereas those attracted to males usually prefer slightly older children. Pedophi lia involving female victims is reported more often than Pedophilia involving male victims. Some individuals with Pedophilia are sexually attracted only to children (Exclusive Type), whereas others are sometimes attracted to adults (Nonexclusive Type). ind ividuals with Pedophil ia who act on their urges w ith children may li mit their acti vity to undressing the child and looking, exposing themselves, masturbating in the presence of the chil d, or gentle touching and fond ling of the child. Others, however, perform fellatio o r cunnilingus on the child or penetra te the child 's vagina, mouth, or anus w ith their fingers, foreign objects, or penis and u se varying d egrees of force to do so. These activities are commonly explained with excuses or rationalizations that the}' have "educational value" for the child, that the child derives "sexual p leasure" from them, or that the child was "sexually provocative"-themes that .lre .llso common in pedophilic pornography. Because of the egosyntonic natu re of Pedophilia, many individuals w ith pedophilic fant<l sies, urges, or behaviors do not experience significant distress. It is important to understand that experiencing dis tress abou t having the fan tasies, urges, or beh<lviors is not necessary for a diagnosis of Pedophilia . Individuals w ho have a pedophiHc arousa l pattern and act on these fantasi es or urges with a child qualify for the diagnosis of Pedophilia. Individuals may limit their activities to their own children, s tepchildren, or relatives or may victimize children outside their families. Some individuals with Pedophilia threa ten the child to prevent disclosure. Others, particularly those who frequently victimize children, d evelop compiic<lted techniques for obtaining access to children, which may include winning the trus t of a child 's mother, marrying a woman w ith an aHr<lctive child, trading children with other individuals w ith Pedophilia, or, in rare instances, taking in foster children from nonindustrialized countries or abducting children fTOm s trangers. Except in cases in which the disorder is associated with Sexual Sadis m, the person may be attentive to the child 's need s in order to gain the child's affection, interest, and loyalty and to prevent the child from reporting the sexual activity. The disorder usually begins in adolescence, although some individuals with PedophiHa report that they did not become aroused by children until middle age. The frequency of pedophilic behavior often fluctuates with psychOSOCial stress. The course is u sually chronic, especially in those attracted to males. 111e recidivism rate for individuals with Pedo philia involving a preference for males is roughly twice that for those who prefer females.
572
B. The pe rson has acted o n these sexual urges, o r the sexual urges o r fantasies cause marked distress or interpe rsona l difficulty .
C. The pe rson is at least age 16 years and at least 5 yea rs older than the child or children
in Criterion A.
Note:
Speci fy if;
Sexu a lly Attracte d to Males Sexu a lly Attracte d to Fe males Sexu a lly Attracte d t o Both
Spe cify if:
Lim it e d to Incest
Specify type:
Exclusive Type (attracted only to children) Nonexclu sive Type
302 .83
Sexual Masochi sm
The paraph ilic focus of Sexual M asochis m involves the act (real, no l s imula ted) o f being hwnilialed, beaten, bo und, o r othenvise made to s uffe r. Some individua ls are both ered by their masochistic fa ntasies, w hich m ay be invoked d u ring sexual inlercourse o r m asturbation but no t o then vise a cted o n . In such cases, the masochis tic fantasies usua lly involve being ra ped w hile bei ng held or bound by othe rs so that the re is no possibility of e sca pe. O thers ac t on the m asochis tic sexual urges by themse lves (e.g., binding them se lves, sticking them selves with pins, shocking the mselves electrically, or self-mutilation) o r w ith a p a rtner. M asochis tic acts tha t m ay be sou g ht wilh a pa rtner include res traint (physical bondage), blindfolding (sensory bondage), paddling, s panking, whipping, bea ting, electrical s hocks, c utting, " p inn ing and p ie rcing" (infibula tio n), and humiliation (e.g., being urina led or defecate d o n, be ing forced to crawl a nd bark like a d og, o r be ing s ubjected 10 verbal abuse). Fo rced cross-dressing may be sough t for its hwnilia ting associa tio ns. 111e individua l rna}' have a d es ire to be t.reated as a helpless infa nl and clothed in diapers ("infantilism " ). One particularly dangero us fo rm of Sexua l Masochism; caJled " hypoxyphiJia," involves sexual arousal by oxygen de privation obtained by means o f chest compressio n, noose, ligature, plastic bag, mas k, o r chemical (ofte n a volatile nitrite tha t produces a te mpo ra ry d ecrease
302 .84
Sexual Sadism
573
in brain oxygenation by perip heral vasodilation). O xygen-depriving acti vities may be engaged in alone or with a partner. Beca use of equipmen t malfunction, errors in the placement of the noose or Ligature, or other mis takes, accidental dea ths sometimes occur. Data from the United States, England, Australia, and Canada indicate that one to h vo hypoxyp hilia-ca used deaths p er million po pula tion are detected and reported each year. Some males w ith Sexual Masochism also have Fetishis m, Trans\cstic Fetishis m, or Sexual Sadism . Masochistic sexual fantasies are likely to have been present in childhood . The age at which masochistic activities with pa rtners fi rst begins is variable, but is commonly by early adulthood . Sexu al Masochism is us ually chronic, and the person tends to repeat the same masochi stic act. Some individuals with Sexual Masochism m ay engage in masochis tic acts fo r many years withou t increas ing the potential injurious ness of their acts. O thers, however, increase the severity of the masochistic acts over time or during periods o f s lTess, which may eventually resuit in injury or even death.
302.84
Sexual Sadism
The par.lphilic focus o f Sexual Sadism involves acts (real, not simulated) in w hich the individ ual d erives sexual excitement from the psychological or p hysical s uffering (including h umilia tion) of the victim. Some indiv iduals with this Paraphilia are bothered by their sadis tic fantasies, w hich rna}' be invoked during sexual activit)' but not otherwise acted on; in such cases the s adis tic fantas ies us ually involve having complete conlTol over the victim, w ho is terrified by anticipation o f the impending sadistic act. O thers act on the sad is tic sexual urges with a consenting partner (who may have Sexual Masoch is m) w ho willingly s uffers pain or humiliation . Still others with Sexual Sadism act on their sadis tic sexual u rges w ith nonconsenting victims. In all of these cases, it is the s uffering of the victim that is sexually arousing . Sad is tic fantasies or acts may involve activities that indica te the dominance of the person over the victim (e.g., forcing the victim to crawl or keeping the victim in a cage). They may also involve res traint, blindfold in g, paddling, spanking, w hipping, pinching, beating.. burning, electrica l shocks, rape, cutting, s ta bbing, stran gulation, tortu re, mutiJation, or killing. Sadis tic sexual fan tasies are likely to have been p resent in childhood. The age at onset of sadistic activ ities is variable, but is commonly by early aduHhood. Sexual Sadism is u sually chronic. When Sexual Sadis m is practiced w ith nonconsenting partners, the activity is likely to be repeated un til the person with Sexual Sadism is app rehended . Some individuals wi th Sexual Sad ism may engage in sadistic acts for
S74
man}' years w ithout a need to increase the potential for inflicting serious physical damage. Usuall}', however, the severity of the sadis tic acts increases over time. When Sexual Sadi sm is severe, and especially when it is associated with Antisocial Personality Disorder, individuals with Sexllal Sadism may seriously injure or kill their victims.
person.
B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
302.3
Transvestic Fetishism
11le paraphilic focus o f Transvestic Fetishism involves cross-dressing by a male in women's attire. In many or most cases, sexual arou sal is produced by the accompanying thought or image of the person as a fem ale (referred to as "autogynephilia"). These images can range from being a woman with female genitalia to that of a view of the self fully dressed as a woman with no real attention to genitalia. Women's garments are arousing primarily as symbols of the individual's femininity, not as fetishes with specific objective properties (e.g., objects made of rubber). Usu ally the male with Transvestic Fetis his m keeps a collection of female clothes that he inte rmittently u ses to cross-dress. This disorder has been described only in heterosexual males. Transvestic Fetishis m is not diagnosed w hen cross-dress ing occurs exclus ively during the course of Gender Identity Disorder. Transvestic phenomena range from occasional solitary wearing of female clothes to extensive involvement in a transvestic subcul- ture. Some males wear a single item of women's apparel (e.g., underwear or hosiery) under their masculine attire. Other males with Transvestic Fetishism dress entirely as females a nd wear makeup. The degree to w hich the cross-dressed indiv idual successfull y appears to be a female varies, depending on mannerisms, body habitus, and cross-dressing s ki ll. When not cross-dressed, the male with Transvestic Fetishism is usually unremarkably mascu line. Although h is basic preference is heterosexual, he lends to have few sexual partners and may have engaged in occas ional homosexual acts. An associa ted fea ture may be the presence of Sexual Masochism. The d isorder typically begins w ith cross-dressing in childhood or early adolescence. In many cases, the cross-dressing is not done in public until ~dulthood. The initial experience may involve pa rtial or total cross-dressing; partial cross-dressing often progresses to completecross-d ressing. A favored ar ticle of clothing may become erotic in itself and may be used habitually, first in masturbation and later in intercourse. In some individuals, the motivation for cross-dressing may change over time, temporarily o r permanently, w ith sexual arous. 1in response to the cross-dress ing diminishing or disappearing. In , s uch instances, the c ross-dressing becomes an antidote to anxiety or depression or
302.82
Voyeurism
575 /
contributes to a sense of peace and calm . In o ther individuals, gender dysphoria may emerge, especially under situational s tress with or without symptoms of depression. For a smaU number of individuals, the gender d ysphoria becomes a fixed part of the clinical picture and is accompanied by the desire to dress and live permanently as a fema le and to seek hormonal or surgica l reassignmen t. IndividuaJs wi th Transvestic Fetishism often seek trea tment when gend er dysphoria emerges. The subtype With Gender Dysphoria is provided to allow the clinician to note the presence of gender dysphoria as part of T ransves tic Fetishism.
With Gender Dysphoria: if the person has persistent discomfort with gender role or identity
302.82
Voyeurism
The paraphilk focu s of Voyeurism involves the act of observing wlsuspecti ng individuals, usually s trangers, who are naked, in the process of disrobing, or engaging in sexual activity. The act of looking ("peeping") is for the purpose of achieving sexual excitement, and gener.llly no sexual activity with the observed person is sought. O rgasm, usually produced by mas turbation, may occur during the voyeuristic acti\' ity or later in response to the memory of what the person has witnessed. Often these indh'iduals have the fantasy of having a sexual experience w ith the observed person, but in reality this rarely occurs. In its severe form , peeping cons titutes the exclusive fo rm of sexual acti vity. The onset of voyeuristic behavior is usually before age 15 ye.us. The course tend s to be chronic.
576
302. 9
This category is included fo r cod ing Para philias that d o not meet the criteria fo r any o f the s pecific categories. Examples include, but are not limited to, telephone scatologia (obscene phone calls), necro philia (cor pses ), pa rtialis m (exclus ive foclls on pa rt of body), zoophilia (an imals), coprophilia (feces), kUs ma philia (enemas), a nd urophilia (u rine) .
577 1
may refuse to attend school or social events w here such clothes may be required. They prefer boys' clothing and short hair, are often misidentified by strangers as boys, and may ask to be ca lled by a boy's name. Their fanta sy heroes are mos t often powerful male fi gures, such as Batman or Superman. These girls prefer boys as playmates, w ith whom they share interests in contact sports, rough-and-tumble play, and traditiona l boyhood games. They show little interes t in d olls or any fo ml of fe minine dress-up or role-play activity. A girl w ith this disorder may occasiona lly refuse to urinate in a sitting position. She may claim that she has or will grow a penis and may not wa nt to grow breasts or to menstruate. She may assert that she w ill g row up to be a ma n. Such g irls typically reveal marked cross-gender iden tification in role-playing, dreams, and fanta sies. Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex . This preoccupation may be manifested as an in tense desire to adopt the social role of th e other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Adults with this disorder are uncomfortable being regarded by others as, or fun ctioning in society as, a member of their deSignated sex. To varying degrees, they adopt the behavior, dress, and mannerisms of the other sex. In private, these individuals may spend much time crossdressed and working on the appearance of being the other sex. Many attempt to pass in public as the o ther sex. With cross-dressing and hormonal treatment (and for males, electrolysis), many individuals with this disorder may pass convincingly as the other sex. The sexual activity of these individuals w ith same-sex partners is generally constrained by the preference that their partners neither see nor touch their genitals. For some males who present later in life (often foll owing marriage), the individual's sexual activity with a woman is accompanied by the fan tasy o f being lesbian lovers or that his partner is a man and he is a woman. In adolescents, the clinical features may resemble either those of children or those of adul ts, depending on the individual's d evelopmental level, and the criteria should be applied accordingly. In a younger ad olescent, it may be more difficult to arrive at an accurate diagnosis because of the adolescent's guardedness. This may be increased if the adolescent feels ambivalent about cross-gender id entification or feels that it is unacceptable to the fantil y. The adolescent may be referred because the parents or teachers are concerned about soci.al isolation or peer teasing and rejection. In such circumstan ces, the diagnosis should be reserved for those adolescents wh o appear quite cross-gender identified in their dress and who engage in behaviors that suggest significant cross-gender identifica tion (e.g., shaving legs in males). Clarifying the d iagnosis in children and adolescents may require monitoring over an extended p eriod of time. Distress or d isability in individuals with Gender Identity Disorder is manifested differently across the life cycle. In young children, distress is manifested by the s tated unhappiness about their assigned sex. Preoccupation w ith cross-gender wishes often interferes with ordinary activities. In older child ren, failure to develop age-appropriate same-sex peer relationships and skills often leads to isolation and distress, and some children may refuse to attend school because of teasi.n g or pressure to dress in attire stereotypical of their assigned sex. l.n adolescents and adults, preoccupation with cross-gender wishes o ften interferes w ith ordinary activities. Relationship difficulties are common, and func tioning at school or at work may be impaired.
578
Specifie rs
For sexually matu re ind ividuals, the follow ing s pecifiers may be noted based on the individual's sexu al orientation: Sexu ally Attracted to Males, Sexu ally Attracted to Females, Sexually Attracted to Both, and Sexu ally Attracted to Neither. Males with Gender Identity Disorder include substantial p roportions w ith all four sp ecifi ers. Those who are attracted to m ales usually first experience the d isorder beginning in
childhood or early adolescence, while those males attracted to females, both genders, or neither usually report their gender dysphoria beginning in ea rly to mid-adult
hood . Those men attracted to nei ther gender are often isola ted ind ividuals with sch izoid tra its. Virtually all females with Gender Identity Disorder will receive the same
specifi er- Sexually Attracted to Females-although there are exceptional cases involving females w ho are Sexually Attracted to Males.
Recordi ng Procedures
The assigned diagnostic code depends on the ind ividual's current age: if the disorder occurs in childhood, the code 302.6 is used; for an adolescent or adult, 302.85 is used.
579
as nude women, focu sing on their imagined breasts and vulvas; o thers masturba te while picturing themselves engaged in some stereoty pically feminine activity such as knitting . Associated laboratory findings . There is no diagnostic test specific for Gender Identity Disorder. In the presence of a nonnal physical examination, ""ryotyping for sex chromosomes and sex hormone assays are usually not indica ted. Psychological testi ng may reveal cross-gender identification o r behavior pa tterns. Associated physical examination findings and general medical conditions. Individuals with Gender Identity Disorder have nomlal genitalia (in contrast to the ambiguous genitalia or hypogonadism fou n d in physical intersex conditions). Adolescent and adult males w ith Gender Identity Di sorder may show breast enlargement resulting from hormone ingestion, hair den uding from temporary or permanent epilation, and other physical dmnges as a resu lt of procedures such as rhinoplasty or thyrOid ca rl"ilage shav iJlg (surgical red uction of the Ad am's apple). Distorted breasts or breast rashes may be seen in fema les who wear breast binders. Postsurgical complications in genetic females include prominent chest wal1 scars, and in genetic males, vagi nal strictures, rectovaginal fi stulas, ure thr.1l stenoses, and misd irected urinary streams. Adult fema les w ith Gender Identity Disorder may ha ve a h.igher-thanexpected likelihood of polycystic ovarian d isease.
Preva lence
There are no recent epidemiological studies to provide data on prevalence of Gender Identity Disorder. Da ta from smaller countries in Europe w ith access to total populCltion statistics and referrals suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery.
Co urse
For ciinicalJ}' referred children, onset of cross-gender interests and acti vities is usually beh veen ages 2 and 4 years, and some paren ts report that their ch ild has always had cross-gender interests. Only a very small number of children with Gender Identity Disorder w ill continu e to have symptoms that meet criteria for Gender Identity Disord er in adolescence or adulthood. Typ ically, children are referred around the time of school entry b ecause of parental concern that w hat they regi1rded as a "phase" does not appear to be passing. Most children with Gender Identity Disorder dis play
1 580
less overt cross-gender behaviors with time, parental intervention, or resp onse from peers. By late adolescence or adulthood, about three-quarters of boys who had a
childhood history of Gender Identity Disorder report a homosexual or bisexual orientation, but without concurrent Gender Identity Disorder. Most of the remainder report a heterosexual orientation, also without concurrent Gender Identity Disorder. The corresponding percentages for sexual orientation in girls are not known. Some adolescents may develop a clearer cross-gender identifica tion and request sexreassignment surgery or may continue in a chronic course of gender confusion or dysphoria. In adult males, there are two d ifferent courses for the development of Gender Identity Disorder. The first is a continuation o f Gender Identity Disorder that had an onset in childhood. These individuals typically prescnt in late adolescence or adulthood . In the other co urse, the m ore overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood usually follo wing, but sometimes concurrent with, Transvestic Fetishis m. nle later-onset group may be more flu ctuating in the degree of cross-gender identification, more ambivalent about sex-reassignment surgery, more likely to be sexually attracted to women, and less likely to be satisfied after sex-reassignment surgery. Males with Gender Identity Disorder who are sexually attracted to males tend to present in adolescence or early adulthood with a lifelong history of gender dysphoria. In contrast, those who are sexually attracted to females, to both males and females, or to neither sex tend to present later and typically have a history of Transvestic Fetishism. Typically, after sex reassignment, those males who were attracted to females wish to live w ith another woman in either a lesbian relationship or as sisters. U Gender Identity Disorder is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported .
Differential Diagnosis
Gender Identity Disorder can be distinguished from simple nonconfonnity to stereotypical sex-role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities. This disorder is not meant to d escribe a child's nonconfonnity 10 stereol)' pic sex-role behavior as, for example, in "tomboyishness" in girls or "sissyish" behavior in boys. Rather, it represents a profqwld di..sturbance of the ind iv idual's sense of identity with regard to maleness or femaleness. Behavior in children that merely d oes not fit the cultura l stereotype of masculinity or feminin il)' should not be given the diagnosis unless the full syndrome is presen t, including marked distress or impainnent. Transvestic Fetishism occurs in heterosexual (or bisexual) men for whom the cross-dressing behavior is for the purpose of sexual excitement. Aside from crossdresSing, most indiv iduals with Transvestic Fetishism do not have a history of childhood cross-gender behaviors. Males w ith a presentation that meets full criteria for Gender Identity Disord er as well as Transvestic Fetishism should be given both diagnoses. U gender dysphoria is present in an individual w ith Transvestic Fetishism but full criteria for Gender Identity Disorder are not met, the specifier With Gender Dysphoria can be used. The category Gender Identi ty Disorder Not Otherwise Specified can be used for
Gender Identity Disorder individ uals w ho have a gender id entity problem w ith a con current congen ital intersex cond ition (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia). In Schizophrenia, there may rarely be delusions of belonging to the other sex. Insistence by a person with a Gender Id entity Disorder that he or she is of the other sex is not considered a delusion, because what is invariably meant is that the person feels like a member of the other sex rather than truly believes that he or she is a member of the other sex. in very rare cases, ho wever, Schizophrenia and severe Gender Identity Disorder may coexist.
tence on wearing only stereotypica l masculine clothing (3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the o t her sex (4) intense desire to participate in the stereotypica l games and pastimes of the othersex (5) strong preference for playmates of the othe r sex In adolescents and adults, the d isturbance is manifested by symptoms such as a stated desire to be t he other sex, frequ ent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he o r she has the typical feel ings and reactions of the other sex.
B. Persistent discomfort with his o r he r sex or sense of inappro priateness in the gender
ro le of that sex. In children, the d isturbance is manifested by any of the following : in boys, assertion that his penis or testes are d isgusting or will d isappear o r assertion that it would be better not to have a penis, o r aversion toward rough-andtumble play and rejection of ma le stereotypica l toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or wi ll grow a pe nis, o r assertion that she does not want to grow breasts or menstruate, or marked aversio n toward normative feminine clothing. In adolescents and adults, the d isturbance is manifested by symptoms such as preoccupation w ith getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characte ristics to simulate the other sex) o r belief that he or she w as born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition .
D. The disturbance causes clinica lly significant dist ress or impairment in social, occupa tional, o r other important areas of functioning .
582
302.6
302.85
to to to to
302.9
This ca tegory is included for coding a sexual disturbance that does not meet the criteria for any specific Sexual Disorder and is neither a Sexual Dysfunction nor a Paraphilia. Examples include 1. Marked feelings of inadequacy concerning sexual performance or other traits related to self-imposed standards of masculinity or femininity 2. Distress abou t a pattern of repeated sexuijl relationships involving a succession of lovers who are experienced by the individual only as things to be used 3. Persistent and marked distress about sexual orientation
Eating Disorders
he Eating Disorders are characterized by severe disturbances in eating behavior. Thi s section includes two s pecific diagnoses, Anorexia Nervosa and Bulimia er\fosa. Anorexia Nervosa is characterized by a refusal to maintain a minimally normal body weight. Bulimia Nervosa is characterized by repeated episodes of b inge eating followed by inappropriate compensatory behaviors such as self-induced vomiting; mi suse of laxatives, d iuretics, or other medications; fasting; or excessive exercise. A dish.ubance in perception of body shape and weight is an essen tial feature o f both Anorexia Nerva sa and Bu li mia Nervos<l. An Eating Disorder Not Otherwise Specified category is also provided for coding disorders that do not meet criteria for a specific Eating Disorder. Simple obesity is included in the Ifltemntiollnl C/assijicntiofl of Diseases (TCD) as a general medical condition bu t does not appear in DSMIV because it has not been es tablished that i t is consistently associated with a p sycho logical or behav ioral syn drome. However, when there is evidence that psychological factors are of importance in the etiology or course of a particular case of obesity, this can be indicated by noting the presence of Psychological Factors Affecting Medical Condi tion (p. 731). Disorders ofFeecling and Eating that are usually first d iagnosed in infancy or early childhood (i.e., Pica, Rumination Disorder, and Feeding Disorder of Infancy o r Early Childhood) are included in the section " Feeding and Eating Disorders of Infancy or Early C hildhood " (p. 103).
307.1
Diagnostic Features
Anorexia Nervosa
The essential features o f Anorexia Nervosa are tha t the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight. and exhibits a significant disturbance in the perception of the shape or size of his or her body. In addition, poshnenarcheal females w ith this disorder are amenorrheic. (The term aflorexin is a misnom er because loss of appetite is rare.) The individual maintains a body weight that is below a minimally normal level for age and height (Criterion A). When Anorexia Nervosa develops in an individual during childhood or early adolescence, there may be failure to make expected weight gains (i.e., while growing in height) instead of weight loss. Criterion A provides a guideline for determining when the individual meets the threshold for being underweight. It suggests that the individual weigh less than 85% of that weight that is considered normal for that person 's age and height (usually
583
1 584
Eating Disorders
compu ted using one of several published versions of the MetTopolitan Life Insurance tables or pediatric g rowth charts). An alternative and somewhat stricter g uideline (used in the lCD-tO Diagnos tic Criteria fo r Research) requires that the individual have a body mass index (Btvll) (calcula ted as weight in kilograms / height in meters 2) equ al to or below ] 7.5 kg / m l, These cutoffs are provided o nly as s uggested guidelines for the clinician, since it is unreasonable to specify a single standard for minimally normal weight that applies to all individua ls of a given age and height. In determining a minimally normal weight, the clinician s hould consider not only such guidelines but also the individual's body build and weight his tory. Usually weigh t loss is accomplished primarily through reduction in total food intake. Although individua ls may beg in by excluding from their diet what they perceive to be h ighly caloric foods, most eventually end up with a very res tricted diet that is somet imes limited to only a few fo od s. Additional methods of weight loss include purging (i.e., self-induced vom iting or the misuse of laxatives or diuretics) and increased or excessive exercise. Individ ua ls with this disorder intensely fear ga ining weight or becoming fa t (Criterion B). TIlis intense fear o f becoming fat is usually not allevia ted by the weight loss. In fact, concern about weight gain often increases even as actual weight continues to decrease. The experience and significance of body weight and shape are distorted in these individuals (Criterion C). Some ind ividuals feel g lobally ovenveig ht. Others realize that they are thin but are s till concerned that certain pa rts of their bodies, particularl)' the abdomen, buttocks, and thighs, are " too fa L" They may employ a wide variety of techniques to estimate their body s ize or weight, incl uding excessive weighing, obsessive measuring of body parts, and persistently us ing a mirror to check for perceived areas of " faL " The self-esteem of indi viduals with Anorexia Nervosa is highly eight loss is viewed as an impressi\'e d ependent on their body shape and weigh t. ' ,\T achievemen t and a s ign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control. Tho ugh some individ uals with this disorder may acknowledge being thin, they typically deny the serious medical implications of their malnourished s tate. in postmenarcheal fe males, amenorrhea (due to abnormally low levels of estrogen secretion that are due in tum to diminished pituitary secretion of fo llicle-stim ulating honnone IFSH j and luteinizing hormone [LHj) is an indicator of p hysiological d ysfunction in Anorexia Nervosa (Cri terion D). Ameno rrhea is us ually a consequence of the weight loss but, in a minori ty of individuals, may actually precede it. In prepubertal females, menarche may be delayed by the illness. The ind ividual is often brought to professional attention by famil y members after marked weight loss (or failure to make expected weight gains) has occurred . If ind ivid uals seek help on their own, it is usually because of their subjective dis tress over the somatic and psychological sequelae of starvation. It is rare for an individual with Anorexia Nen 'osa to complain of weight loss per sc. lndividuals w ith Anorexia Nervasa frequently lack insight into, or have considerable d enial of, the problem and may be unreliable historians. It is therefo re often necessary to obtain information from parents or other outside sources to evaluate the degree of weight loss and other features of the illness.
Subtypes
The foll owing subtypes can be used to specify the presence o r absence o f regular
binge eating or purging during the current episode of Anorexia
~estrictin g Type.
ervosa:
This subtype describes presentations in which weight loss is accomplished p rimarily through dieting, fas ting, o r excessive exercise. During the current episode, these individuals have not regula rly engaged in binge eating or purging . Binge-Eatin glPurging T ype. This sub type is used when the ind ividual has regularly engaged in binge eati ng or pu rging (or both) during the current episode. Most individuals with Anorexia Nervosa who binge eat also purge through self- induced vomiting or the misuse of laxatives, d iuretics, orenemas. Some individuals included in this subtype d o not binge ea t, but do regularly purge after the consumption of small amounts of food. It appears that most individuals with Binge-Ea ting / Purging Type engage in these behaviors at least weekly, but sufficient information is not available to justify the specification of a minimum frequency.
586
Eating Disorders
their his tory, and to ha ve a personality disturbance that meets criteria for Borderline Personality Disorder.
Associat e d laboratory find ings. Although some individuals with Anorexia NerVOSil exhibit no laboratory abnormalities, the semjstarvation characteristic of this disorder ca n affect most major organ systems and produce a variety of disturbances. The induced vomiting and abuse of laxatives, diuretics, and enemas can also cause a number of dis turbances leading to abnormal laboratory findings. Hematology: Leukopenia and mild anemia are common; thrombocytopenia occurs rarely. Cllemistry: Dehydration may be reflected by an elevated blood urea nitrogen (8U ). Hypercholesterolemia is common. Uver function tests may be elevated. Hypo-magnesemia, hypozincemia, hypophosphatemia, and hyperamylasemia are occasionally found . Induced vomiting may lead to metabolic alkalosis (elevated serum bicarbonatel- hypochloremia, and hypokalemia, and laxative abuse may cause a metabolic acidosis. Serum thyroxine (Tol) levels are usually in the low-normal range; triiodothyron ine (T) levels are d ecreased. Hyperadrenocorticism and abnormal responsiveness to a variety of neuroendocrine challenges are common. In females, low serllm estrogen levels are present, w hereas males have low levels of serum testosterone. There is a regression of the hypothalamic-pituita ry-gonadal axis in both sexes in that the 24-hour pattern of secretion of luteinizing hormone (LH) resembles that normally seen in prepubertal or pubertal individuals. ElectromrdiograpllY: Sinus bradycardia and, rarely, arrhy thmias are observed . Elecfroellceplmlograplly: Diffuse abnomlalities, reflecting a metabolic encephalopathy, may result from significant fluid and electrolyte disturbances. Braill imaging: An increase in the ventricular-brain ratio secondary to starvation is often seen. Resting energy expenditllre: This is o ften significantly reduced .
Ass ociated physical examination f indings and general me dical conditions.
Many of the physical signs and s}' mptoms of Anorexia Nervosa are attributable to starvation. In addition to amenorrhea, there may be complaints of constipation, abdominal pain, cold intolerance, lethargy, and excess energy. The most obvious fmdin g on physical examination is emaciation. There may also be significant hypotension, hypothermia, and dryness of skin . Some individuals develop lanugo, a fine d owny body hair, on their trunks. Most individuals with Anorexia Nervosa exhibit bradycardia. Some de\'elop peripheral edema, especially during weight restoration oron cessation of laxative and diuretic abuse. Rarely, petechiae, usually on the extremities, may indicate a bleeding diathesis. Some individuals evidence a yellowing o f the skin associated with hypercarotenemia. Hypertrophy of the salivary glands, particularly the parotid g lands, may be present. Individ uals who induce vomiting may have dental enamel erosion and some may have scars or calluses on the dorsu m of the hand from contact w ith the teeth when using the hand to induce vomiting. The sem istarvation of Anorexia Nervosa, and the purging beha viors sometimes associated with it, can result in significant associated general medical conditions. These include the development of normochromic normocytic anemia, impaired renal function (associa ted with chronic dehydration and hypokalemia), cardiovascular
587
problems (severe hypotension, arrhythmias), dental problems, and osteoporosis (resulting from low ca lcium intake and absorp tion, reduced estrogen secretion, and increased cortisol secretion).
Prevalence
The lifetime prevalence of Anorexia Nervosa among females is approximately 0.5%. Individuals who are subthresh old fo r the d isorder (Le., with Ea ting Disorder Not Otherwise Specified) are more commonly encountered. The prevalence of Anorexia Nervosa among males is apprOxima tely one-tenth that among females. The incidence of Anorex ia Nervosa appears to h ave increased in recen t d ecades.
Course
Anorexia Nervosa ty p ically begins in m id - to la te ad olescence (age 14-18 years). The onset of th is disorder rarely occu rs in females over age 40 years. 111e onset of illness may be associated w ith a stressfu l life event. The course and outcome of Anorexia Ncrvosa arc high ly variable. Some ind ividuals w ith Anorexia Nervosa recover fuJly after a single episode, some exhibit a fl uctuatin g pa ttern of weight gain followed by relapse, and others exp erience a chronically deteriorating course of the illness over many years. With time, particularly w ithin the firs t 5 years of onset, a significant fraction o f individuals with the Restricting Type of Anorexia Nervosa develop binge eating, ind ica ting a change to the Binge Eating/ Purging subtype. A sustained shift in clinical p resentation (e.g., weight gain plus the presence of binge ea ting and purging) may even tually wa rrant a change in diagnosis to Bulimia 'ervosa. Hosp italization may be required to restore weigh t and to address fluid and electrolyte imbalances. O f ind ivid uals admitted to university hospitals, the long-term
588
mortality from Anorexia Nen'osa is over 10%. Death mos t commonly results from s tarvation, suicide, or electrolyte imbalance.
Familia l Pattern
There is an increased risk of Anorexia Nervosa among fust---degree biological relatives of individuals with the disorder. An increased risk of Mood Disorders has also been found among fi rst-degree biological relatives of individuals with Ano rexia Nervosa, particularly relatives of ind ividuals with the Binge-Eating / Pu rging Type. Studies of Anorexia ' ervosa in twins have found concordance rates for monozygotic twins to be significantly higher than those for dizygotic h\'ins.
Differential Diagnosis
Other possible causes of significant weight loss shou ld be consi dered in the differential diagnOSiS of Anorexia Nervosa, especially when the presenting features are atypical (such as an onset of illness after age40years). In ge neral medical conditions (e.g., gastrointestinal disease, brain tumors, occult ma lignancies, and acquired immunodeficiency syndrome [AIDS}), serious weight loss may occur, but individuals with su ch disorders usually do not have a distorted bod y image and a desire for further weight loss. The s uperior mesenteric artery syndrome (characteri zed by postprandial vomiting secondary to intermittent gastric outlet obstruction) should be distinguished from Anorexia Nervosa, although this syndrome may sometimes develop in individuals with Anorexia Nervosa bccauseof their emaciation. In Major Depressive Disorder, severe weight loss may occur, but most ind ividuals with Major Depressive Disorder do not have a desire for excessive weight loss or excessive fear of gaining weight. In Schizophreni a, individuals may exhibit odd eating behavior and occasionaHy experience s ignificant weight loss, but they rarely s how the fear of gaining weight and the body image disturbance required for a diagnosis of Anorexia Nervosa. Some of the features of Anorexia Nervosa are part of the cri teria sets for Social Phob ia, Obsessive-Compuls ive Disorder, and Body D ysm or phic Disorder. Specifically, individuals may be humiliated or embarrassed to be seen ea ting in public, as in Social Phobia; may exhibit obsessions and compu ls ions related to food, as in Obsessh'e-Compulsive Disorder; or may be preoccupied with an imagined defect in bodily appearance, as in Body Dysmorphic Disorder. If the individual with Anorexia Nervosa has social fears that are limi ted to eating behavior alone, the diagnosis of S0cial Phobia should not be made, but social fears unrelated to eating behavior (e.g., excessive fear of speaking in public) may warrant an additional diagnosiS of Social Phohi.l. Similarly, an ad ditional diagnosis of Obsessive-Compuls ive Disorder s hould be considered only if the individual exhibits obsessions and compulSions unrelated to food (e.g., an excessive fear of contamination), an d an additional diagnosis of Body Dysmorphic Disorder should be considered only if the distortion is unrelated to body shape and size (e.g., p reoccupa tion that one's T).ose is too big). In Bulimia Nervos a, individuals exhibit recurrent episodes of binge ea ting, engage in inappropriate behavior to avoid weight gain (e.g., self-induced vomiting), and are overly concemed w ith body shape and weight. However, unlike individuals with
589
Anorexia Nervosa, Binge-Eating/ Purging Type, individuals with Bulimia NerV05<l are able to maintain body weight at or above a minimall}' normal level.
influence of body weight or shape on self-eva luation, or denial of the seriousness of the current low body weight.
D. In postmenarcheal females, a menorrhea, i.e., t he absence of at least three consecu-
tive menstrual cycles. (A woman is considered to have amenorrhea if her periods 0(cur only following hormone, e.g., estrogen, administration.)
Specify type:
Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i .e., self-induced vomiting or the misuse of laxatives, diuretic;, or enemas) Binge-Eating/Purging Type : during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., selfinduced vomiting or the misuse of laxatives, diuretics, or enemas)
307.51
Diagnostic Feature s
Bulimia Nervosa
The essential features of Bulimia iervosa are binge ea ting and inappropriate compensatory methods to prevent weight gain. In addition, the self-evaluation of individuals w ith Bulimia Nervosa is excessively influenced by body shape and weight. To qualify for the diagnosis, the binge eating a nd the inappropriate compensatory behaviors mus t occur, on a verage, at leas t twice a week for 3 months (Criterion C). A b;flge is defined as eating in a discrete period of time an amount of food that is definitel y larger than most individuals would eat under s imilar circumsta nces (Criterion A 1). The clinician should consider the conlext in which the eating occurredwhat would be rega rded as excessive conswnption at a typical meal m ight be considered normal during a celeb ration or holiday meal. A "discrete period of time" refers to a limited period, u sually less tha n 2 homs. A s ing le episode of binge eating need not be restricted to one setting . For example, an individual may begin a binge in a restaurant and then continue it on returning home. Continual snacking on smal1 amounts of food throughout the d ay wo uld not be cons idered a binge. Although the type of food cons umed during binges varies, it typically includes
1 590
Eating Disorders
sweet, high-calo ric foods such as ice cream or cake. However, hinge eating appears to be characterized more by an abnormality in the amount of food cons umed than by
a craving for a s pecific nutrient, s uch as carbohyd ra te. Although indiv iduals with Bulimia Nervosa cons ume more calories during an episode of binge ea ti.ng than p ersons without Bulimia 'ervosa consume during a mea\, the fra ctions of calories d erived
307.51
Bu limi a Nervosa
591
exercise d espite injury or other medical complications. Rarely, indiv iduals with this disorder may take thyroid hormone in an attempt to avoid weight gain. Individuals \\'ith d iabetes mellitus and Bul imia Nervosa rna)' omit o r reduce insulin doses in order to reduce the metabolis m of food consumed during ea ting binges. Individuals with Bulimia Nervosa place an excessive emphasis on body shape and \\"eight in their seif-evaluation, and these factors are ty pically the most important ones in determining self-es teem (Criterion D). Individua ls with this disorder may closely resemble those with Anorexia Nervosa in their fear of gain ing weight, in their desire to lose weight, and in the level of dissatisfaction w ith their bod ies. However, a diagnosis of Bulimia Nervosa s hould not be given when the disturbance occu rs only during episodes o f An orexia Nervosa (Criterion E).
Subtypes
The following subtypes ca n be used to specify the presence or absence of regula r use of pmging methods as a means to compensa te for the binge eating: Purging Typ e. This subtype describes presentations in wh ich the person has regularl)' engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current epi sode. Nonp urging Type. Th is subtype describes presenta tions in which the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularl}' engaged in self-induced vomiting or the mis use of laxatives, diu retics, or enemas d uring the curren t episode.
592
Eating Disorders
uals with Bulimia Nervosa al so ha ve personality feahl res that meet criteria for one or more Personal ity Disorders (mos t frequ ently Borderline Personality Disorder). Preliminary evidence sugges ts tha t individuals with Bulimia I ervosa, Purging
T}'pe, show more symptoms of depression and greater concern with shape and weight than individuals wi th Bulimia e rvosa, Nonpurg ing Type.
Associated laboratory findings. Frequent purging behavior of any kind can produce fluid and electrolyte abnonnalities, most frequen tly hypokalemia, hyponatremia, and hy pochloremia. The loss of s tomach acid through vomiting may produce a metabolic alkalosis (elevated serum bicarbonate), and the frequ ent induction of diarrhea
through laxative abuse can ca use metabolic acidosis. Some individuals with Bulimia Nervosa exhibit mildly elevated levels of serum amylase, probably reflectin g an increase in the sa livary isoenzyme. Recurrent vomiting eventually leads to a significant and permanent loss of dental enamel, especially from ling ual surfaces o f the fron t teeth. These teeth may become chipped and appear ragged and " moth-eaten. " There may also be an increased frequency of denta l cavities. In some individuals, the sali vary glands, partku lari}' the parotid glands, may become notably enlarged. Ind ividuals who induce vom iting by manually stimulating the gag reflex may develop calluses or scars on the dorsal surface of the hand from repeated trauma from the teeth. Serious cardiac and skeletal m yopathies have been reported among individuals who regu larly use syrup of ip ecac to induce vomiting. Menstrual irregularity or amenorrhea sometimes occurs among fema les with Bulimia Nervosa; whether such disturbances are rela ted to weight fluctuatio ns, to nutritional deficiencies, or to emotional stress is uncertain. Individuals who chronically abuse laxatives ma y become dependent on their use to stimulate bowel movements. The flu id and electroly te disturbances resu lti.ng fro m the purging behavior are sometimes sufficiently severe to constitute medically serious problems. Rare but poten tially fa tal complica tions include esophageal tears, gastric rupture, and cardiac arrhythmias. Rectal prolapse has also been reported among individuals wi th this disorder. Compared w ith indi viduals w ith Bulimia Nervosa, Nonpurging Type, those with the Purging Type are much m ore likely to have physical problems such as fluid and electroly te disturbances.
Associated physical examination findings and general medical conditions .
307. 51
Bulimia Nervosa
Prevalence
The lifetime p revalence of Bulimia Nervosa among women is approximately 1%-3%; the rate of occurrence of this disorder in males is approxima tely one-tenth of that in females.
Course
Bulimia Nervosa u sually begins in late adolescence or early adult life. The binge ea ting frequentl y begins during or after an epi sode of dieting. Disturbed eating behavior persists for at least severa l years in a high percentage o f clinic samples. The course may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating. However, over lon ger-term follow -up, the symptoms of many individuals appear to diminish. Periods o f remission longer than 1 year are associated with better long-term outcome.
Differential Diagnosis
Individ uals whose b inge-eating behavior occurs only during Anorexia Nervosa are given the diagnosis Anorexia Nervosa, Binge-Eating/Purging Type, and should /l ot be gi ven the addi tional diagnosis of Bulimia Nervosa. For an individual who binges and purges bu t whose p resentation no longer meets the full criteria fo r Anorexia Nervosa, Binge-Eating/ Pu rging Type (e.g., when weight is nomMI or menses have become regular), it is a matter o f clinical judgmen t whether the most appropriate current diagnosis is Anorexia fervosa, Binge-Ea ting / Purging Type, In Partial Remission, or Bulimia N ervosa . In certain neurological or other general medical conditions, such as Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psychological features of Bulimia Nervosa, such as overconcern with body shape and weight, are not present. Overea ting is common in Major Depressive Disorder, With Atypi cal Fea tures, but s uch individ uals do not engage in inappropria te compensatory behavior and d o not exhibit the characteristic overconcern with body shape and weight. If criteria for both disorders are met, both diagnoses s hould be given. Binge-eating behavior is included in the impulsive behavior criterion that is part of the definition of Borderline Personality Disorder. if the full criteria for both disorders are met, both diagnoses can be given.
594
Eating Disorders
of food that is definitely larger than mort people would eat during a similar period of time and under sim ilar ci rcumstances (2) a sense of lack of (Ontrol over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain.
such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate com pensatory behaviors both occur, o n average,
at least twice a week fo r 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Specify type:
Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting o r excessive exercise, but has not regularly engaged in self-induced vomit ing o r the misuse of laxatives, diuretics, or enemas
307.50
595
6. Binge-eating disorder: recurren t episodes of binge eating in the absence of the regular lise of inappropriate compensatory behaviors characteristic of Bulimia Nervosa (see p. 785 for su gges ted research criteria).
Sleep Disorders
T he s leep disorders are organized into fo ur major sections according to presumed etiology. Primary Sleep Disorders are those in which none of the etiologies lis ted below (i.e., another mental disorde r, a general medical condition, or a substance) is responsible. Prima ry Sleep Disorders are preSlmled to arise from endogenous abnormalities in sleep-wake generating or timing mechanisms, often complicated by conditioning fac tors. Primary Sleep Disorders in tum a re s ubdivided into Dyssomnias (characterized by abnormalities in the amount, quality, or timing of sleep) and Parasomnias (characterized by abnormal behavioral or physiological events occurring in association w ith sleep, specific sleep s tages, or sleep-wake transitions). Sleep Disorder Related to An other Mental Disorder involves a prominen t complaint of sleep d isturbance tha t results from a diagnosable mental disorder (often a ~'Iood Disorder or Anxiety Disorder) but that is sufficiently severe to warrant independent clinical attention. Presumably, the pathophysiological mechanis ms responsible for the mental disorder also affect sleep-wake regulation. Sleep Disorder Due to a General Medical Condition in volves a prominent complaint of sleep dis turbance that results from the direct physiological effects of a general medical condi tion on the sleep-wake system . Substance-Induced Sleep Disorder involves prominent complaints o f sleep dishubance that resu lt from the concurrent use, or recent d iscontinuation of lise, of a substance (including medications). The systema tic assessment in individuals who present with prominent complaints of sleep d is turbance includes an evaluation of the specific type of sleep complaint and a consideration of concurrent mental disorders, general medica l conditions, and substance (including medication) u se that may be resp onsible for the sleep disturbance. Five distinct sleep stages can be m easured by p o\ysomnography: rapid eye movement (REM) sleep and four s tages of non-rapid eye movement (NREM) sleep (stages 1,2,3, and 4). Stage 1 NREM sleep is a transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults. Stage 2 NREM sleep, w hich is characterized by specific EEG waveforms (sleep spindles and K complexes), occupies about 50% of time s pent asleep. Stages 3 and 4 N REM sleep (also known collectively as slow-wave sleep) a.re the deepest levels of sleep and occupy abou t 100/..--20% of sleep time. REM sleep, d uring which the majority of ty pical storylike dreams occur, occupies about 200/..--25% of total sleep. These sleep s tages ha ve a characteris tic temporal organiza tion across the night. NREM stages 3 and 4 tend to occur in the first one-third to one-hali o f the night and increase in duration in resp onse to sleep deprivation. REM sleep occurs cyclically throughout the nigh t, alternati ng with NREM sleep about every 80-100 minutes. REM sleep p eriods increase in duration toward the morning . Human sleep also varies characteristically across the life s pan. After relative stability with large amounts of slow-wave sleep in chilcUlOOd and early adolescence, sleep continuity and depth de-
597
1 598
Sleep Disorders
teriorale across the adult age range. Thi s deteriora tion is reflec ted by increased wakefulness and s tage I sleep an d d ecreased stages 3 and 4 sleep. Because of this, age must be considered in the diagnosis of a Sleep Disorder in any individ ual. Polysolllllogmphy is the monitoring of mu ltiple eJectrophysiologicaJ parameters during s leep and generally includes measureme nt of EEG activity. electrooculographiCactivity. and elcctromyographic activity. Additional polysomnographic measures may include Ofal or nasal airflow, respiratory effort, chest and abdominal wall movement, oxyhemoglobin sa turation, or exhaled carbon dioxide concen tration; these meas ures a f C used to monitor respiration during s leep and to d e tect the presence and severity of sleep apnea. Measurement o f peripheral electromyographic activity may be used to detect abnormal movements during sleep. Most polysomnographic s tud ies are conducted during the person's usual sleeping hours-that is, at night. However, daytime polysomnographic s tudies also are used to q uantify daytime sleepiness. The most common d aytime procedure is the 1\'lultiple Sleep La tency Tes t (MSLT), in w hich the individual is ins tructed to lie d own in a dark room and not resis t fa ll ing asleep; this pro tocol is repeated five times during the day. Sleep latency (the amount o f time required to fa ll asleep) is measured on each trial and is used as an index of phYSiolog ical sleepiness. The converse of the MSLT is also used: In the Maintenance of Wakefulness Tes t {Mlo"'D, the indi vidual is placed in a quiet, dimly lit room and ins tructed to remain awake; this protocol is repeated several times during the d ay. Again , sleep latency is measured, b ut it is lIsed here as an index o f the individual's abili ty to maintain wakefulness. Standard terminology fo r polysomnographic measures is u sed throughou t the text in this section. Sleep cOlltiJwily refers to the overall ba lance of sleep and wakefulness d uring a night of sleep . "Better" sleep con tinuity indicates consolidated sleep with little wakefulness; "worse" sleep continuity indicates d isru pted sleep with more wakefulness. Sp ecific sleep continui ty measures include sleep latency- the amount of time required to fa ll asleep (expressed in minutes); intermit/ellt wakefiliness-the amount of awake time after initial sleep onset (expressed in minutes); and sleepeJjiciellcy-the ratio o f actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity). Sleep nrchitecture refers to the amoun t and distribution of specific sleep stages. Sleep archi tecture measures include absolute amounts of REM sleep and each NREM sleep s tage (in minutes), relative amount of REM sleep and N REM sleep s tages (expressed as a percen tage of total sleep time), and la lency between sleep onset and the first REM period (REM la tency). The text for each of the Sleep Disorders contains a section describing its relationship to corresponding disorders in the Tile 1utematiol/al Classification Of Sleep Disorders: (lCSD) Diag nostic and Coding Mmllfal, published in 1990 by the American Sleep Disorders Association.
Dyssomnias
Dyssomnias arc primary disorders of initia ting or main taining sleep o r of excessive sleepiness and are characterized by a dis ttubance in the amount, q uality, or timing of
307.42
Primary Insomnia
599
sleep. This section includes Primary Insonutia, Primary Hypersomnia, I arcolepsy, Breathing-Rela ted Sleep Disorder, Circadian Rhythm Sleep Disorder, and Oyssom nia Not Otherwise Specified.
307.42
Diagnostic Feat ures
Primary Insomnia
The essentia l feature of Primary Insonmia is a complaint of difficulty initiating or maintaining sleep or of nonrestorative sleep that lasts for at leas t 1 month (Criterion A) and causes clinically significant dis tress or impairment in social, occupational, or other important areas of ftmctioning (Criterion B). The disturbance in sleep does not occur exclusively during the course of another sleep disorder (Criterion C) or mental disorder (Criterion D) and is not due to the direct physiological effects of a substance or a general medical condition (Criterion E). Individuals with Primary Insomnia mos t often report a combination of difficulty falling asleep and intermittent wakefulness during sleep. The s pecific type of sleep complaint often va ries over time. For ins tance, individuals who complain of difficulty falling asleep at one time may later complain of difficulty maintaining sleep, and vice versa. Less commonly, individuals with Primary Insomnia may complain only of nonrestorative sleep--that is, feeling that their sleep was restless, light, or of poor quality. Not all individuals with nigh ttime sleep disturbances are distressed or have functiona l impai rmen t. A diagnosis of Primary Insomnia s hould be reserved for those indi viduals w ith significant distress or impairmen t. Primary Insomnia is often associated w ith increased physiological , cognitive, or emotional arousal in combination with negative conditioning for sleep. A marked preoccupation with and dis tress due to the inability to sleep may contribute to the development of a vicious cycle: the more the individual s tri ves to sleep, the more fru strated and dis tressed he or she becomes and the less he or s he is able to sleep. Lying in a bed in w hidl the individual has frequentl y spent sleepless nights may cause frustration and conditioned arousaltCollversely, the individual may faU asleep more easily when not trying to do so (e.g., whi le watching televis ion, re.lding, or riding in a car). Some individuals with increased arousal and nega ti ve conditioning report that they sleep bettcr away from their own bed rooms and their u sual routines. Individuals w ith Primary Insomnia may thereby acqui re ma ladaptive sleep habi ts (e.g., daytime napping, spending excessivc time in bed, following an erratic sleep schedule, performing sleep-incompatible behaviors in bed) during the course of the disorder. Chronic insomnia may lead to decreased feelings of weU-bcing during the day (e.g., deterioration of mood and motivation; decreased attention, energy, and concentr.ltion; and an increase in fatigue and malaise). Although individuals often have the subjective complaint of daytime fatigue, polysonmographic s tudies us ually do not demons trate an increase in p hysiol ogical signs of sleepiness.
1 600
Sleep Di sorders
opmen! of more persistent sleep problems. Other associated factors may include anxious overconcern with general health and increased sensitivity to the daytime effects of mild sleep loss. Symptoms of anxiety or depression that do not meet criteria
for a specific mental disorder may be p resent. Interpersonal, social, and occupational problems may develop as a result of overconcem with sleep, increased da ytime irritability, and poor concentration. Problems with inattention and concentration may also lead to accidents. Individuals w ith severe insomnia have grea ter fLmctional impairmen t, lower producti vity, and increased health care utilization compa red with individuals without sleep complaints. Individuals with Primary Insomnia may also report interpersonal and work-related stress. Individuals with Primary Insomnia may have a history of mental disorders, particularly Mood Disorders and Anxiety Disorders. Primary Insomnia also constitutes a risk facto r for (or perhaps an early symptom of) subsequent Mood Disorders, Anxiety Disorders, and Substance Use Disorders. Individuals w ith Primary Insomnia so metimes use med ications inapp ropriately: hypnotics or a lcohol to help with nighttime sleep, anxiolytics to combat tension or anxiety , and caffeine or other stimulants to combat excessive fatigue. In some cases, this type of substance use may progress to Substance Abuse or Substance Dependence. Associated laboratory findings. Polysomnography often demonstrates poor sleep continuity (e.g ., increased sleep latency, increased intermiHent wake fuln ess, and decreased sleep efficiency) and may demonstrate increased stage 1 sleep and decreased stages 3 and 4 sleep. O ther labora tory findings may include increased muscle tension and increased amoun ts of alpha and beta activity during sleep as mea sured by quantitative EEe ana lysis. These features must be interpreted within the con text of age-appropriate nom's. Polysomnographic measures often show considerable va riability from night to n ight. individuals with Primary lnsomnia may also ha\'e substantial d iscrepancies beh\'een subjective and p olysomnog raphic measures of sleep quanti ty, most commonly in the direction of underestimating sleep amount. Some individuals may report better sleep in the laboratory than at home, suggesting a conditioned basis for sleep compla ints. lndividuals with Primary insomnia typically do not have increased daytime sleepiness as measured by sleep laboratory testing compared with individuals w ithout any Sleep Disorders. O th er psychophysiological tests may also show high arousal (e.g., increased muscle tension, excessive p hysiolog ical reactivity to stress, and increased metabolic rate). Individuals with Primary Insomnia may also have e levated scores on self-report psychological or personality in ventories (e.g., on profiles indicating chronic, mild depression and anxiety; an " internalizing" style of connict reso lution; and a somatic focus). Measures of neu rops}'ch ological test performance d o no t show consistent patientS of impainnent among individuals with Primary Insomnia. Associated physical examination findings and general medical conditions . Individuals with Primary Insomnia may app ear fatig ued or haggard but show no other characteristic abnormalities on physical examination . There may be an increased incidence of stress-related psychophysiological problems (e.g., tension headache, increased muscle tension, gastric distress).
307.42
Preva lence
There are few data regarding the prevalence of Primary lnsonmia in the general population. Population surveys indica te a 1-year p revalence of insomnia complaints of 300/ -45% in adults. The prevalence o f Primary Insomnia is approximately 1 %~10% 0 in the general adult population and up to 25% in the elderly. In dinics specializing in sleep disorders, approximately 1 5%~25% of individuals with chronic insomnia are diagnosed with Primary Insomnia.
Cou rse
The factors that precipitate Primary Insomnia may differ from those that perpetuate it. Most cases have a fa irly sudden onset a t a time of psychological, social. or medical stress . Prima ry Insomnia o ften p ersists long after the original causative fa ctors resolve, due to the development of heightened arousal and negative conditioning. For example, a person with a painful inju ry who spends a grea t deal of time in bed and has difficulty sleep ing may then develop nega ti ve associations for sleep. Nega tive associations, increased arousal, and conditioned awakenings may then persis t beyond the con valescent period, leading to Primary Insomnia. A similar scenario may develop in association with insomnia that occurs in the context of an acute psychological stress or a mental disorder. For instance, insomnia that occurs during an episode of Major Depressive Disord er can become a focus of attention w ith consequent nega tive conditioning, and insomnia may persis t long after resolution of the depressive episode. In some cases, Primary Insomnia may d evelop gradually wi thout a clear stressor. Primary Insomnia typically begins in young adulthood or middle age and is rare in dilldhood or adolescence. In exceptional cases, the insomnia can be documented back to childhood. The course of Primary lnsorrmia is variable. It may be limited to a period of several months, particularly if precipitated by a psychosocial or general medical s tressor tha t later resolves. However, approximately 50%.....75% of individuals
602
Sleep Disorders
with insom nia complaints have chronic symptoms las ting for more than 1 year, and previous insomnia is the strongest single risk factor for current msonmia, Some individuals experience an episodic course, w ith periods of better or worse sleep occurring in response to life events s uch as vacations or stress.
Familial Pattern
The predisposition toward light and disrupted s leep has a familia l association . Li mited d ata from twin s tudies have yielded inconsisten t results regarding the importance o f genetic factors in Primary Insomnia .
Differential Diagnosis
"Normal" sleep duration varies considerably in the general population. Some individuals w ho require little sleep ("short sleepers") may be concerned about their sleep duration . Short sleepers are distinguished from those with Primary Insomnia by their lack of d ifficu lty fa lling asleep and by the absence of characteristic symptoms of Primary Insomnia (e.g., intermittent wakefulness, fatigue, concentration problems, or irritability). However, some short sleepers are uninformed as to their abbreviated biological need for sleep, and in their attempt to prolong time in bed, they create an insomnia sleep pattern. Daytime sleepiness, wh ich is a characteristic feature of Primary Hypersomnia, may infrequently occur in Primary Insonmia but is not as severe. 'Nhen daytime sleepiness is judged to be due to insomnia, an additional diagnosis o f Prima ry Hypersomnia is not given. Jet Lag and Shift Work Typ es of Circadian Rhy thm Sleep Dis order are distinguished from Primary Insomnia by the history of recent transmeridian travel or shift work. Individuals with the Delayed Sleep Phase Type of Circadian Rhythm Sleep Disorder report sleep-onset insomnia only when they try to sleep at socially normal times, but they do not report difficulty falling asleep or staying asleep when they sleep at their preferred times. Narcolepsy may cause insomnia co mplaints, particularly in older adults. However, Narcolepsy rarely involves a major complaint of insonmia and is d is tinguished from Primary Insomnia by symptoms of prominent daytime sleepiness, ca taplexy, sleep paralysis, and sleep-rela ted hallucinations. Breathing-Related Sleep Disorder, particularly central sleep apnea, may involve a complaint of chronic insomnia and d aytime impaimlent. However, clinically significant sleep apnea is an uncommon finding among otherwise h ealthy young and midd le-aged individuals with chronic insomnia (although it may be more common in the elderly). A careful history may reveal periodic pauses in breathing during sleep or crescendo-decrescendo breathing (Cheyne-Stokes respiration). A h istory of central nervous system injury or disease may further suggest a Breathing-Related Sleep Disorder. Polysomnography can confirm the presence of apneic even ts. Most individuals with Breathing-Related Sleep Disorder have obstructi ve apnea that can be distinguished from Primary Insom nia by a h istory of loud snoring, brea thing pauses dwing sleep, and excessive daytime sleep iness. Parasomnias are characterized by a complaint of unusual behavior or events dw-
307 .42
Prima ry Insomn ia
603
ing sleep thnt sometimes may lend to intermittent awakenings. However, it is these behnvioral events that dominnte the clinical pichue in a Parasollmia rather than the . . msonmla. Primary Insomnia mus t be distinguished from m ental disorders that include insomnia as an essential o r associated feature (e.g ., Mnjor Depressive Disorder, Generalized Anxiety Disorder, Schizophrenia). The diagnosis of Primary Insomnia is not given if insonmia occurs exclusively during the course of another mental disorder. A thorough investigation for the presence of other mental di sorders is essential before considering the d iagnosis of Primary Insonmia. A diagnosis of Primary Insomnia can be made in the presence of another current or pas t mental disorder if the ment,ll disorder is jud ged to no t account for the insomnia or if the insonmia and the ment,ll disorder have an independent course. ,"Vhen insomnin occurs as a manifestation of, and excl usively during the course of, another mental disorder (e.g., a Mood, Anxiety, Somatoform, or Psychotic Di sorder), the d iagnosis of Insomn.ia Related to Another Mental Disorder may be more appropriate. This diagnosis should only be considered when the insollmia is the predominan t complaint and is suffi ciently severe to warrant independen t clinical attention; otherwise, no separate d iagnosis is necessary. Clinical fea tures su ch as nega tive conditioning and poor sleep h ygiene are more consistent wi th a diagnosis of Primary in somnia, whereas clinically significant nonsleep symptoms (e.g., d epressed mood, anxiety) and a chronic, severe course of insomnia are more common in indi vid uals with In somnin Related to Another Mental Disorder. In clinical settings, polysollmography is not typicnlly u seful in the differential diagnosis of Primary Insomnia versus Insomnia Related to Another Men tal Disorder. Primary Insomnia must be distinguished from Sleep Dis order Due to a General Medical Condition, Insomnia Type. The diagnosis should be Sleep Disorder Due to a General Medical Condition when the i.nsomnia is judged to be the direct physiological consequence of a specific gen eral medical cond ition (e.g ., pheochromocytoma, hyperthyroidism, congestive heart fa ilure, dlfonic obstructive pulmonary disease) (see p . 651). This determination is based on history, laboratory findings, or physical exam in ation. Substance-Induced Sleep Di sorder, Insomnia Ty pe, is distinguished from Primary Insomnia by the fac t that a substance (i.e., a drug of abu se, a medication, or exposure to a toxin) is judged to be etiologically related to the insonmia (see p. 655). For example, insollm.ia occurring only in the context of heavy coffee constunption would be diagnosed as Caffeine-Induced Sleep Disorder, Insomnia Type, With Onset During lntoxication.
604
Sleep Disorders
refers to insomnia resulting from behavioral practices that increase arousal or d isrupt sleep organization (e.g., working late into the night, taking excessive daytime naps,
D. The dist urbance does not occur exclusively du ring the cou rse of anothe r mental disorder (e.g .. Major Depressive Disorder. Ge nera lized Anxiety Disorder, a delirium). E. The disturbance is not due to the direct physiologica l effects of a substance (e.g .. a drug of abuse. a medication) or a general medical condition.
307.44
Diag nostic Features
Primary Hypersomnia
The essential feature of Prima ry Hyp ersomnia is excessive sleepiness for at least 1 month as evidenced either by prolonged sleep episodes or by daytime sleep episodes occurring almos t daily (Criterion A). The excessive sleepiness mus t be sufficiently severe to cause clinically significant d istress or impairment in social, occupational, or other important areas of functi oning (Criterion B). The excessive sleepin ess does not occur exclusively during the cou rse of another Sleep Disorder (Cri terion C) or mental disorder (Criterion 0 ) and is not due to the d irect ph}'sioiogical effects of a substance or a general medica l condition (Criterion E). In individuals with Primary Hypersomnia, the duration of the major sleep episode (for most ind i\'idua ls, n octurnal sleep) may range from 8 to 12 hours and is often fol lowed by difficulty awakening in the morning. The actual q uality o f nocturnal sleep is no rmal. Excessive sleepiness during normal waking hours takes the form of intentional naps o r inadvertent episodes of sleep. Objective meas urements demonstrate increased physiological sleepiness. Daytime naps tend to be relatively long (often lasting an hour or m ore). are experienced as unrefreshing, and often d o not lead to improved alertness. individuals typically feel sleepiness developing over a period of tim e, rather than experiencing a s udden sleep "attack." Unintentional sleep episodes ty pically occur in low-s timulation and low-.activity situations (e.g., while attending lectures, reading, watching television, or d riving long d istan ces). Hypersomnia can lead to Signifi cant distress and dysfun ction in work and social relationships. Prolonged nocturnal sleep and difficulty awakening can result in diffi-
307.44
605
cult)' in meeting morning ob ligations . Unintentional daytime sleep episodes can be embarrassing and even dangerous, if, for instance, the ind ividual is driving or operating machinery when the episode occurs. The low level of alertness that occurs w hile an individual fights sleepiness can lead to poor efficienc)" poor concen tration, and poor memory during daytime activities. Sleepiness, often misa ttributed to boredom or laziness, can also disrupt SOCi,ll and family relationships.
Speci fi er
Recurrent. This specifier is used if there are periods of excessive sleepiness that last at leas t 3 days occurring several times a year for at least ") years. Most individuals with Prim,l ry Hypersomnia have consistent and persistent symptoms. In contrast, the Recurrent form s hould be noted if symptoms occur periodically for several days to several weeks, with symptomatic periods recurring several times per year. Between periods o f excessive sleepiness, sleep dmation and daytime alertness are normal. In the recurrent form of Primary Hypersoomia known ,1S Kleine-Levin syndrome, individuals may spend 18-20 hours asleep or in bed. The recurrent periods of sleepiness are associated with other characteris tic clinical features indicating disinhibition. Indiscriminate hypersexuality including inappropriate sexual advances and overt masturbation can be seen in males (and less often in females). Compulsive overeating with acute weight gain may occur. irritabili ty, d epersonaliza tion, depression, confusion, and occasional hallucinations have been described in some individuals, and impulsive behaviors can also occur. Other recurrent forms of hypersollmia can be seen in the absence of these feahlres. For instance, some females report regularly occurring period s of hypersomnia a t s pecific times of their menstrual cycle.
606
Associated laboratory finding s.
Sleep Disorders
In Primary Hypersonmia, nocturnal POiYSOOU10g-
raphy demonstrates a normal to prolonged sleep duration, short sleep latency, normal to increased sleep continuity, and nomlai dis tributions of rapid eye movement (REM) and non-rapid eye movemen t (NREM) sleep. Some individuals w ith this dis-
order may have increased amounts of slow-wave sleep. Increased spindle density during stage 2 sleep may be present. Sleep-onset REM periods (the OCCUI'rence of
REM sleep within 20 minutes of sleep onset), breathing-related s leep disturbances, and frequent limb movements disrupting sleep are not present. The Multiple Sleep Lalency Tes t (~\!ISL documents excessive physiological daytime s leepiness, ty pically indicated by mean s leep latency values of 5--10 minutes_ REM sleep does not occur during the daytime s leep episodes. ' octurnal polysomnography and the MSLT do not reveal findings cha racteristic of o ther causes of hypersomnia. in the Recurrent Kleine-Levin form of Primary H}'persomnia, routine EEG s tudies performed during the periods of h}'persornn.ia s how general s lowing of the background rhythm and paroxysmal bursts of theta activity. Nocturnal polysomnography shows an increase in total sleep time and sho rt REM sleep latency. MSLT s tudies confirm increased physiological sleepiness, with s leep latencies generally less than 10 minutes. Sleep~onset REM periods may be seen during symptomatic periods.
Associated physical e xa mination findings and general medical conditions . individua ls with Primary H ypersomnia often appear sleepy and may even fall asleep in the clinician's waiting area. A s ubset of individuals with Primary H ypersomnia have a family history of hypersomnia and also have symptoms of au tonomic nerVOliS system dys function, induding recurrent vascular-type headaches, reacti vity of the peripheral vascular system (Raynaud's phenomenon), and fainting . lndividuals with the Recurrent KleineLevin form may have nonspeCific neurolOgical examination findings induding depressed deep tendon reflexes, d ysarthria, and nystagmus.
Preva lence
The true prevalence of Primary H ypersomnia in the general population is not known. Approximately 5/0-10% of indi viduals who present to sleep di sorders clinics with com p laints of daytime s leepiness are diagnosed as having Primary H ypersomnia. TI,e Recurrent form of Primary H ypersomnia known as Kleine-Levin syndrome is rare. Popula tion s urveys find a complaint of daytime sleepiness in 0.5~~5.0% of adults, w ithout rega rd to s pecific causes or diagnoses. After other conunon causes are accounted for, the lifeti me prevalence of clinically significan t hypersomnia is at least 16%, and the incidence over approximately a 4year inter va l is abou t 8%.
307.44
607
Course
Primary Hypersomnia typically begins between ages 15 and 30 years, with a gradual prog ression over weeks to months. For most indi viduals, the course is then chronic and stable, unless treatment is initiated . 11le development of other sleep disorders (e.g ., Breathing-Related Sleep Disorder) ma y worsen the degree of sleepiness. KleineLevin syndrome also begins during adolescence and may continue its periodic course fo r decades, although it often resol ves during middle age.
1 608
hveen sleep and wakefulness (e.g., sleep-rela ted hallucinations and sleep paralysis). The MSLT typ ica lly demonstrates shorter sleep latencies (i.e., greater physiological sleepiness) as well as the presence of multiple sleep-onset REM periods in individ uals with Na rcolepsy. Individuals with Primary Hypersomnia and Breathing-Related Sleep Disorder may have similar patlems of excessive sleepiness. Breathing-Rela ted Sleep Disorder is s ugges ted by a his tory of loud s noring, pau ses in breathing during sleep. brain injury, or ca rdiovascula r d isease and by the p resence of obes ity, oropharyngeal anatom ica l abnorma lities, hyp ertension, or heart fail ure on physical examination. Polysomnographic studies can confi rm the presence of apneic even ts in BreathingRelated Sleep Disord er (and thei r absence in Primary Hypersomnia) . Circadian Rhythm Sleep Disorder is o ften characterized by daytime sleepiness. A history of an abno rmal sleep-wake sch edule (w ith shifted or irregular hours) is present in ind ividuals with Circadian Rhythm Sleep Disorder. Pa rasomnias rarely p roduce the prolonged , undisturbed nocturnal sleep or daytime sleepiness characteristic of Primary Hyperso mnia. Primary Hypersomnia must be distinguished from m en tal di sorders th at include hypersomnia as an essential or associated feature. in particu lar, complaints of daytime sleepiness may occur in a Majo r Depressive Episode, With Atyp ical Features, and in the d ep ressed p hase of Bipolar Disorder. The diagnosis of Primary Hypersomnia is not given if hypersomnia occurs exclusively during the course of another men tal d isorder. A thorough investigation for the presence of other mental disorders is essential before considering the diagnosis of Primary Hypersomnia. A diagnosis of Primary Hypersomnia can be mad e in the presence of another current o r past mental disord er if the men tal d isorder is judged to not account for the hypersomnia or if the hypersomnia and the mental disord er have an independent course (e.g., in an individual with chronic hypersomnia who later develops a Major Depressive Disorder). in contrast, when hypersomnia occu rs as a manifesta tion o f, and exclusively d uring the course of, another mental d isorder, the diagnosis o f Hypersomnia Related to Another Mental Disord er may be more appropri ate. This d iagnosis should only be considered when the hypersomnia is the predominant complaint and is sufficiently severe to warran t independent clinical atten tion; otherwise, no separate diagnosis is necessary. In general, labora tory testing of d aytime sleepiness in individ uals with H ypersomni a Related to a Mental Diso rder often shows normal or only mild levels of physiological sleepiness compared with individual s with Primary Hypersomnia . Primary H ypersomnia m ust be d istinguished from Sleep Disorder Due to a General Medical Condition, Hypersomnia Type. The d iagnosis is Sleep Disorder Due to a General Medical Condition w hen the hypersomnia is judged to be a d irect p hysiological consequ ence o f a specific general medical condition (e.g., morbid obesity, brain tu mor) (see p. 651). This determina tion is based on history, laboratory findings, or physical examination. Substance-Induced Sleep Di sorder, Hypersomnia Type, is distinguished from Pri mary Hypersomnia by the fact that a substance (i.e., a d rug of abuse, a medication, o r exposure to a toxin) is judged to be etiologically related to the hypersomn ia (see p. 655). For example, hypersomnia occurring only in the con text of withd rawal from cocaine wou ld be d iagnosed as Cocaine-Induced Sleep Disord er, Hypersomnia Type, \o\/ith Onset During Withdrawal.
347
Narcolepsy
609
D. The disturbance does not occur exclusively during the cou rse of another mental dis order.
E. The disturbance is not due to the direct physiological e Herts of a substance (e.g., a
Recurrent: jf there are periods of excessive sleepiness that last at least 3 days oc curring several times a year for at least 2 years
347
Diagnostic Features
Narcolepsy
TIle essen tial featu res of Narcolepsy are repeated irresistible attacks of refreshing sleep, cataplexy, and recurren t intrusions of elements of rapid eye movement (REM) sleep into the transition period beh\'een sleep an d wakefulness. The individual's sleepiness ty pically decreases after a sleep attack, only to return several hours later. The sleep attacks mus t occur daily over a period of at least 3 months to establis h the diagnosis (Criterion A), although most individuals describe many years of sleep attacks prior to seeking clinical attention. In addi tion to sleepiness, ind ividuals with Narcolepsy experience one or both of the fo llowing : cataplexy (i.e., episodes of s udden, bilateral, reversible loss of muscle tone that las t for seconds to minutes and are usually precipitated by intense emotion) (Cri terion B1) or recurrent intrusions of elements of rapid eye movemen t (REM) sleep into the transition behveen sleep and wakefulness as manifested by p aralysis of volwltary muscles or dreamlike hall ucinations (Criterion B2). Many sleep experts allow the diagnosis to be made in the absence
610
Sleep Disorders
of cataplexy or intrusions of REM sleep elements if the ind ividual demonstrate:! pathological sleepiness and two or more sleep-onset REi\'[ periods during a Multi ple Sleep Latency Test (MSL The symptoms mus t no t bedue to the direct physiological effects of a s ubstance (including a medication) o r a nother general medical cond ition (Criterion C). Although Narcolepsy is classified in the chapter of ICD devoted to neurological conditions, it is included in this section to assist in differential diagnosis in individuals with excessive sleepiness and is coded on Axis L Episodes of sleepiness in Narcolepsy are often d escribed as irresistible, resulting in unintended sleep in inappropriate situations (e.g., while driving an automobile, altending meetings, or carrying on a conversa tion). Low-stimulation, low-activity situations typically exaggera te the d egree of sleepiness (e.g., fallin g asleep while reading, watching television, or attending lectures). Sleep episodes generally last 10--20 minutes but can last up to an hour if uninterrupted . Dreaming is frequentl y reported . Individuals have varying abilities to "fight off" these sleep attacks. Some individuals take naps intentionally in order to manage their sleepiness. Individuals with Narcolepsy typically ha ve 2--6 episod es of sleep (intentional and unintentional) per day w hen untreated. Sleep episodes are usually su perimposed on a more normal d egree of alertness, although some individu als describe constant sleepiness of some d egree. Cataplexy often develops severa l years after the onset of daytime sleepiness and occurs in approximately 70% of individuals w ith the di so rder. The loss of muscle tone with cataplexy may be subtle, leading to a sagging jaw or drooping eyelids, head, or arms not noticeable to observers. Cataplexy can also be more d ramatic, and the indiv idual may drop objects being carried , buckle at the knees, or actually fall to the grou nd. Respiratory and eye muscles are not affected. The muscle weakness usually lasts only seconds, although periods of up to a half hour have been reported . Episodes are followed by a full return of normal muscle streng th. Full consciousness and alertness are preserved during cataplectic episodes. ind ividuals can clearly describe events and have no confusion before or after the episode. Rarely, prolonged episodes of cataplexy Illay lead into sleep episodes . Cataplexy is usually triggered by a strong emotional stimulus (e.g., anger, surprise, laughter). Sleep deprivation typically increases the frequency and severity of episodes of cataplexy. Approximately 20%--40% of individuals with Narcolepsy also experience intense dream like imagery just before fallin g asleep (hypnagogic ha llucinations) or just after awakening (hypno pompic hallucinations). Most sleep-related hallucinations are visual and incorporate elements of the actual environment. For instance, individuals may describe objects appearing through cracks in the wall or d escribe objects moving in a p icture on the \\'aIL The hallucinations may also be auditory (e.g., hearing intruders in the home) or kinetic (e.g., sensation of fl ying). Although hypnagogiC and ar_ hypnopompic hallucinations are important symptoms among individuals w ith E colepsy, these symp toms are also present in approximately 100/0--15% of the general /0 population. Approximately 30%--500 of individuals w ith Narcolepsy also experience sleep paralysis just on falling asleep or awakening . In thi s condition, indiv iduals d escribe being awake but lmable to move or sp eak. They may also comp lain of feeling unable to brea the, although the diaphragm is s pared and respiration continues. It should be noted, however, that 40/ --50% of normal sleepers report having had iso0 lated episodes of sleep paralysis at least once during their lifetime. Sleep-related hallucinations and sleep paralysis may occur Simultaneously, resulting in an often
n.
347
Narcol epsy
611
terrify ing experience of seeing or hearing unusual things and being unable to move. Both sleep-related ha llucinations and sleep paralysis las t for seconds to a few minutes and terminate s pontaneously. Both phenomena (vivid mental imagery and skeletal muscle atonia) are thought to result from di ssociated elements of REM sleep intruding into wakefulness.
Sleep Disorders
Human leukocyte antigen (H LA) typing of individuals with Narcolepsy often shows the presence of HLADQBl~0602. This marker is present in almost all individ uals with Narcolepsy and cataplexy and is independent of racial ethnicity. Howeve.r, HLA DQBl ~0602 is present in only 40% of individuals wi th N arcolepsy w ithout cataplexy and is presen t in 20%-25% of the general population. Other HLA ma rkers vary in terms of their sensitivity and specificity in different racial groups.
Associated physical examination findings and general medical conditions. Individuals with arcolepsy may appear sleep}' during the dinical interview and examination and may actually fall asleep in the waiting area o r examination room . During episodes of cataplexy, individuals may slump in the chair and have slurred speech or drooping eyelids.
Preva lence
Epidemiological studies indica te a prevalence o f 0.02%-0.16% for Narcolepsy in the adult population, with equal ra tes in fem ales and males.
Co urse
Daytime sleepiness is almost always the first symptom of Narcolepsy and usually becomes clinically significant during adolescence. However, on careful review, some degree of sleepiness may have been p resent even during preschool and early school ages. Onset after age 40 is unusual. However, some individuals with I arcolepsy may not identify excessive sleepinl.'Ss as a symptom of an illness. This may explain why many individuals are first diagnosed with Narco lepsy many years after the first onset of symptoms. Acu te psychosocial stressors or acute alterations in the sleep-wake schedule herald the onset in roughly half of cases. Cataplexy may develop concurrently with sleepiness but often appears mon ths, years, or even d ecades after the on set of sleepiness. Sleeprelated hallucinations and sleep paralysis are more variable symptoms of the disorder and may not occur in some individuals. Disrupted noctur nal sleep usually d evelops la ter in the course of the disorder, often when individuals are in their 40s or 50s. TIle excessive sleepiness of Narcolepsy has a stable course over time. The development of other Sleep Disorders (e.g., periodk limb movements or Breathing-Related Sleep Disorder) may worsen the d egree of sleepiness, whereas treatment with stimu lant medications may improve it. Cataplexy usually has a stable course as well, although some individuals report decreased symptoms or e ven complete cessation of symptoms after many years. Similarly, the sleep-related hallucinations and sleep pa ralysis may go into remission while the dayti me sleepiness and sleep attacks persist.
347
Na rco le psy
Familial Pattern
Data from HLA studies and family studies strongly suggest a role for genetic fa ctors in the development of Narcolepsy. The mode of inheritance has not been d etermined but is likely multifac torial. Approximately 50/..-15% of first-degree biological relatives of probands with Narcolepsy have the disorder. Approximately 250/ -50% of the first0 degree biological relatives o f individua ls with Narcolepsy have other disorders cha racterized by excessive sleepiness (such as Primary Hy persomnia).
Differential Diagnosis
Narcolepsy must be d ifferentiated from nonnal va riatio ns in sleep, sleep d eprivation, other primary Sleep Disorders, and Sleep Disorder Related to Another Mental Disorder, Hypersonmia Type. Many ind ividuals feel some sleepiness during the day, pa rticularly in the afternoon hours when an increase in physiological sleepiness occurs. However, such individual s do not have irresistible sleep at other times of the day and can "figh t through" their sleepiness with increased mental and physical effort. They generally do no t experience ca taplexy, sleep-related hallucinations, o r sleep paralysis. Episodes o f muscle weakness may occur in individuals without Narcolepsy. Al though joking and laughing are the most typical triggers of ca taplexy, episodes that are exclusively triggered by stress or tension or tha t occur in the context of physical exertion are less li kely to represent true cataplexy. Sleep d eprivation from any cause produces day time sleepiness. Narcolepsy shou ld be d iagnosed only if the individual ha s demonstrated a regular sleep-wake schedule w ith an ad equa te amoun t of nocturna l sleep. Sleep deprivation and irregular sleep schedules may rarely lead to sleep-related hallucinations or sleep paralysis, but not to cataplexy. The degree of d aytime sleepiness may be similar in individuals WiUl Narcolepsy and Primary Hypersomnia . Compared with individuals with Narcolepsy, individuals w ith Primary Hypersomnia generall}' describe prolonged and less disrupted nocturnal sleep. Daytime sleepiness in Primary Hypersomnia consists of more prolonged, unrefreshing sleep periods, which have less urgency than the sleep "attacks" of Narcolepsy and are less often associated wi th dreaming. Indi\'iduals w ith Primary Hypersomnia d o not manifest cataplexy, sleep-related hallucinations, or sleep paralysis. foctumal polysomnography confirms less disrupted sleep and normal REM latency in ind ividuals w ith Primary Hypersomnia, and the MSLT does not show sleep-onset REM periods. Individ uals w ith Breathing-Related Sleep Disord er often experience excessive sleepiness tha t is equal in magnHude to that of individua ls w ith Narcolepsy. Furthermore, many individuals with N arcolepsy may develop some degree of sleep apnea. Brea thing-Related Sleep Disord er is d istinguished from I arcolepsy by a history of loud snoring; breathing pauses that d isrupt nocturnal sleep; lengthy, u nrefre shing daytime sleep episodes; and the absence o f accessory symptoms such as cataplexy. Polysomnogra phy can identify breathing pauses (apneas) in ind ivid uals with Breathing-Related Sleep Disorder. lf an individual p resents with an unambiguous history of Narcolepsy together with confirmatory pol ysonmographic find ings (sleep-onset REM) and also has evidence of Breathing-Related Sleep Disorder during polysom-
614
Sleep Disorders
nography, both diagnoses can be made. If an individual has sleep-onset REM and sleep apnea activ ity dur ing polysomnography but does not have the full clinical syn-
drome of areeleps)" then onl}' a diagnosis of Breathing-Related Sleep Di sorder should be made.
Individuals with H ypersomn ia Related to Anot her Men tal D isord er may report excessive sleepiness and intense dreams. In particular, Major Depressive Episodes
' '''ith Atypical Features and Bipolar Disorder, Most Recent Episode Depressed, often
involve an intense need fo r sleep during the daytime. However, individuals with Mood Disorders typically ha ve prolonged albeit dis turbed !lochlmal sleep in contrast to the short, frag mented sleep of Narcolepsy. Daytime naps are not refresh ing in individuals with Mood Disorders. Furthermore, these individuals do not have the accessory symptoms that are characteristic of Narcolepsy (e.g., cataplexy), although individuals who have Major Depressive Disorder. With Psychotic Features, rna)' complain of hallucinations near sleep and a t o ther times. Polysomnographic studies of ind ividuals with Mood Disorders may revea l short RErvl latency, but typically not as short as that seen in Narcolepsy. Nocturnal sleep la tency is also longer in individuals with Mood Disorders. Finally, daytime testing with the MSLT shows a much lower degree of physiologica l sleepiness and infrequent sleep-onset REr,,1 periods in individuals w ith Mood Disorders. Thus. the "sleepiness" in these individuals appears to be more a manifestation of psychomotor retardation and anergy. The use of. or w ithdra wal from, s ubs tances (including medica tions) may produce some symptoms of Narcolepsy. Cholinergic agonists (includ ing an ticholines terase pesticid es) can disrupt sleep continuity and enhance REM sleep. Similar effects can result from the abrupt discon tinuation of anticholinergiC agents, including tricyclic antidepressants. Reserpine and methyldopa can enhance REM sleep and produce sleepiness. Withdrawal from stimulants can produce severe somnolence. A d iagnosis of Subs tan ce-I nduced Sleep Disord er, Hypersomn ia Type, might be warranted if the symptoms are judged to be due to the direct physiolog ical effects of a substance (see p. 655). Conversely, a diagnosis of arco lepsy should not be made if the individual is taking or has recently discontinued taking s uch substances. Narcolepsy must be distinguished from Sleep Diso rder Due to a General Medical Co nditi on, Hy persomnia Type. The diagnosis is Sleep Disorder Due to a General Medical Condition when the symptoms are judged to be the direct phYSiological consequence of a specific general medical con.d ition (e.g., closed head injury or hypothalamic tumor) (see p . 651).
780.59
615 /
in association wit h intense emotion) (2) recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes
C. The disturbance is not due to the direct physiological effects of a substance (e.g ., a
780.59
Diagnostic Features
The essen tia l featm e of Breathing-Related Sleep Disord er is sleep disruption, leading to excessive sleepiness o r, less commonly, to insomnia, that is judged to be due to abnormalities of ventilation during sleep (e.g., sleep apnea or central a lveolar hypo\'entilation) (Criterion A). This sleep disruption must not be better accounted for by a mental disorder and is not due to the direct physiological effects of a substance (induding medication) or a general medical condition that produces sleep symptoms through a mechanism other than abnormal breathing (Criterion B). Excessive sleepiness is the most common presenting comp laint of indiv iduals with Breathing-Related Sleep Disorder. Sleepiness res ults from frequent arousals during nochlrna l sleep as the individual attempts to breathe normally. The sleepiness is most e\'ident in relaxing situations, such as when the individual is reading or watdling television. The individual's inability to control the sleepiness can be evident in boring meetings or while attending movies, theater, or concerts. When sleepiness is extreme, the person may fall asleep while actively conversing, eating, walking, or driving. Naps tend to be uruefreshing and may be accompanied by a dull headache on awakening. However, there ca n be considerable variation in the intensity of the sleepiness. The impact of the sleepiness may be minimized by the individual. who may express pride abou t being able to sleep anywhere at any time. Insomnia, frequent awakenings, or unrefreshing sleep are less frequent than daytime sleepiness as the presenting complaint in individuals \\'ith Breathing-Related Sleep Disorder. Some individuals may complain of difficulty breathing while lying supine or sleeping. Abnonnal respiratory events dming sleep in Breathing-Related Sleep Disorder include apneas (episodes of bre.lthing cessation), hypopneas (abnonnally slow or shallow respiration ), and hypoventilation (abnormal blood oxygen and carbon dioxide
616
Sl eep Disorders
levels). Three forms of Breathing-Related Sleep Disorder have been described: air structive sleep apnea syndrome, cenlral sleep apnea syndrome, and central alveolar hypoventi la tion syndrome. An older term, Pickwickillll syndrome, has been used to describe obese individuals with a combination of obstructive sleep apnea syndrome and waking hypoventilation as well as sleep-related hypoventilation. Obstructive sleep apI/en syndrome is the most common form of Breathing-Related Sleep Disorder. It is d ,a racterized by repeated episodes of upper-ai rway obs truction (apneas and hypopneas) during sleep. The central drive for respiration and respiratory movem en ts in the chest and abdo men are preserved . It u sually occurs in overweight individuals and lead s to a complaint of excessive sleep iness. Obstructi ve sleep apnea syndrome is cha racterized by loud snores or brief gasps that alterna te with episodes of silence that u sually last 20-30 seconds. Snoring is cau sed by b reathing throug h a partially obstructed airway. Silent periods are caused by obstructive apneas, with the cessation in brea thing caused by complete airway obstruction. Typ ica lly the loud snoring h as been present fo r many years, often since childhood , but an in crease in its severity may lead the individual to seek evaluation. The snoring is comma n ly loud enough to disturb the sleep of others in close proximity. The cessa tion of breathing, sometimes lasting as long as 60-90 second s and associated w ith cyanosis, may a lso be of concern to bed partners. The term ination of the apneic event can be associated with loud " resuscitative" snores, gasps, moans or mumbling, or whole-body movements. The bed partner may have to move to a sepa rate bed or another room as a result of the affected individual's snoring, gas ps, and m ovements. Most affected indi viduals are Wlaware of the loud snoring, breathing difficulty, and frequent arousals. However, some p ersons, particularly elderly persons, are intensely awa re of the sleep d isturbance and present w ith a complaint of freq uent awakenings and uneefreshing sleep. Some indi viduals without frank airway obstruction may demonstrate arousals associated with increased airway resistance (sometimes referred to as IIpper tlimmy resisttlllce syndrome or respira tory evellt-related flrollstlls). These individuals have many clinica l characteristics in common w ith individuals with obstructi ve sleep apnea syndrome. Central sleep apnea syndrome is cha racterized by episodic cessation of ventilation during sleep (apneas and hypop neas) w ithout airway obstruction. Thus, in contrast to obstructive apnea events, central apneas are not associated with continued chest wall and abdominal breathing movements and occur m ore commonly in elderly persons as a result of card iac or neurological conditions that affect ventilatory regula tion. Ind ividuals most often present w ith complaints of insonu,ia due to repeated awakenings, which they mayor may not associate w ith breathing difficulties. Individuals with central sleep apnea may have mild sno rin g, but it is not a prominen t complaint. The central aiiJf!olar hypoveJ/tiiafioJ/ sYJ/drome is cha racterized by an impairment in ventilatory control that results in abnorma lly low arterial oxygen levels further worsened by sleep (hypoventilati on w ithout apneas or hypopneas). The hmgs in individ uals with this disorder have normal mechanical properties. This form m ost commonly occurs in very overweight individuals and can be associated with a comp laint of either excessive sleepiness or insomnia.
780. 59
617
618
Sleep Di sorders
breathing disturbance. Cardiac arrhythmias commonly occur during sleep in individuals with Brea thing-Related Sleep Disorder and may includ e sinus arrhythmias, prematme ven tricular contractions, atrioventricular block, or sinus arrest. Bradycardia followed by lachyc.1rdia is commonly seen in association with apneic episodes. Frequent nocturnal awakenings and oxyhemoglobin desaruration can result in excessive sleepiness tha t may be detected by the Multiple Sleep Latency Tes t (MSLT) or other tests of daytime sleepiness. Mean sleep latency on the MSLT is often less than 10 minutes and can be less than 5 minu tes (normal is 10-20 minutes). Arterial blood gas measurements while the person is awake are usually normal, but some individuals with severe obstructive sleep apnea syndrome or central alveolar hypoventi lation syndrome can ha ve waking hypoxemia o r hypercarbia . Cephalometric X rays, magnetic resonance imaging (MRI), computed tomography (en, and fiber-optic endoscopy can show obstruction of the u pper airway. Cardiac testing may show evidence of impai red right ventricular function. Individuals may also have elevated hemoglobin or hematocrit values due to repealed nocturnal hypoxemia. Polysomnographic findings in ch ildren differ from those in adults in that most children demonstrate labored breathing, partial obstructive hypoventilation with cyclical desaturations, hypercapnia, parad oxical movements, and snoring.
Associated phys ica l examination findings and general medical conditions. The majority of individuals with the obstructive sleep apnea syndrome and the central alveolar hypoventilation syndrome are oven\'eight and notice an increase in the severity of symptoms with increasing body weight. Upper-airway narrowin g can occur due to excessive bulk of soft tissues. In particu lar, individuals with larger neck sizes (e.g., neck circumference greater than 17 inches in men and greater than 16 inches in women) are at higher risk for obstructive sleep apnea . Obstructive sleep apnea syndrome occurring in individuals of normal or below-nomlal bod}' weight suggests upper-aim'ay obstruction due to definable, localized struchlral abnorma lity, such as a maxillomandibular malformation or adenotonsillar enlargement. J asal airway obstruction may also be present. Indi viduals may have noisy breathing even while awake. Gastroesophagea l reflux w ith severe " heartburn" pain may occur in the obstnlctive sleep apnea syndrome in association with the effort to reestablish breathing during sleep. Individuals with central sleep apnea syndrome less frequently are overweight or have demonstrable upper-airway obstructions. Systemic hypertension with elevated diastolic pressure is commonly associated with Breathing-Related Sleep Disorder. Some individuals, particularly those with chronic obstructive pulmonary disease or alveolar hypoventilation, have continuously low oxygen saturation values during sleep and are predisposed to developing pulmonary hypertension and associa ted right-si ded cardiac faihu e (cor pulmona le), hepatic congestion, and ankle edema. Individuals with Breathing-Related Sleep Disorder may have an underlying abnormality in the neurological control of the upper-airway musculature or ventilation during sleep. Disorders affecting neurological control of ventilation usually manifest as the central sleep apnea syndrome. Some individual s with neurological conditi ons have a specific lesion affecting the control of pharyngeal muscles, which may lead to the obstructive sleep apnea syndrome. Breathing-Related Sleep Disorder can be associated with systemic general medical
619
or neurological conditions. For instance, obstructive sleep apnea may result from tongue enlargement due to acromegaly, lingual thyroid tissue or cysts, or vocal cord paralysis ilS seen in Shy-Drager syndrome. Impaired cardiac fun ction due to reduced cardiac outpu t can result in cen tral sleep apnea, as can neurological conditions that affect the brain stem control of respiration, such as syringobulbia or brain stem tumors.
Preva lence
The preva lence of Breathing-Related Sleep Disorder associClted with obstructive sleep apnea is estimated to be approximately 1%- 10% in the adult p opulation but may be higher in elderly individuClls. The prevalence of Breathing-Related Sleep Disorder also varies considerably as Cl function of the threshold for the frequency of apnea
1 620
Sleep Di sorders
even ts. The prevalence of centra l sleep apnea syndrome is not precisely known but is estimated to be 10% of the Tate of obstructive sleep apnea syndrome.
Course
The obstructive sleep apnea synd rome can occu r a t any age, but most individuals present for evaluation when they are between ages 40 and 60 years (with females more likely to develop obstructive sleep apnea after menopause). Central sleep apnea
is more commonly seen in elderly individuals with central nervous system or cardiac disease. The central a lveolar hypoventilation syndrome and cenlral sleep apnea syn-
Differentia l Diagnosis
Breathing-Relating Sleep Disorder must be differentiated from other causes of sleepiness, such as Narcoleps)', Primary Hyp ersomnia, and Circadian Rhythm Sleep Disorder. Brea thing-Related Sleep Disorder can be differentiated from Narcolepsy by the absence of cataplexy, sleep-related hallucinations, and sleep paralysis and by the p resence of loud s noring, gas p ing during sleep, or observed apneas or shallow breathing in sleep. Daytime sleep episodes in Narcolepsy are characteristically shorter, more refresh ing, and more often associated with dreaming. Breathing-Rela ted Sleep Di sorder shows characteristic apneas or hypoventilation during nocturnal polysomnographic s tudies, and Narcolepsy results in multiple sleep-onset REM periods during the MSLT. Some individuals have concurrent Narcolepsy and Breathing-Related Sleep Disorder. Breathing-Related Sleep Disorder may be distinguished from Primary Hyp ersomnia and Circadi an Rhythm Sleep Disord er based on the presence ofc1inical or laboratory findings of obs tructive sleep apnea, central sleep apnea, or cen tral alveolar hypoventilation syndromes. Definitive differential diagnosis between Primary Hypersomnia and Breath ing-Related Sleep Disorder may require polysomnographic s tudies. Hypersomnia related to a Major Depressive Episode can be distinguished from Breathing-Related Sleep Disorder by the presence o r absence of other characteristic sympto ms (e.g., d epressed mood and loss of interes t in a Major Depressive Episode and snoring and gasping during sleep in Breathing-Related Sleep Disorder).
780.59
621
Individuals with Breath ing-Related Sleep Disorder must also be differentiated from otherwise asymptomatic adults who snore. This differentiation can be made based on the presenting complaint of insomnia or hypersomnia, the grea ter intensity of snorin g, and the presence o f the characteristic history, signs, and symptoms of Breathing-Related Sleep Disorder. For individua ls complaining of insomnia, Primary Insomnia can be differentiated from Breathing-Related Sleep Disorder by the absence of comp laints (or reports from bedpartners) of difficu lty brea thing during sleep and the absence of the histo ry, signs, and symptoms characteristic of Breathing-Related Sleep Di sorder. Nocturnal Panic Attacks may include s}'mptoms of gasping or choking during sleep tha t may be d ifficult to distinguish clinically from Breathing-Related Sleep Disorder. However, the lower frequency of episodes, intense autonomic arousal. and the lack of excessive sleepiness d iffere nti ates nocturnal Panic Attacks from BreathingRela ted Sleep Disord er. Polysomnography in individuals with nocturnal Panic Attacks does not reveal the ty pical pattern of apneas, hypoventilation, or oxygen desaturation characteristic of Breathing-Related Sleep Disord er. Atten tion- Deficit/Hyperactivity Disorder in children may include sympto ms of inattention, academic impairmen t, and hyperactivity, all of which may also be symptoms of chi ldhood sleep apnea. The presence of o ther symp toms and signs of childhood sleep apnea (e.g., labored breathing or snoring during sleep and adenotonsillar hypertrophy) would suggest the presence of a Brea thing-Related Sleep Disorder. The diagnOSiS of Breathing-Related Sleep Disorder is appropriate in the p resence of a gen eral medi cal condition that causes insomnia or h ypersomnia through the mechanism of impaired ventilation d uring sleep. For example, an individual with tonsillar hypertrophy who has sleep difficulty related to snoring and obstructive sleep apneas should receive a diagnosis of Breathing-Related Sleep Disorder on Axis I and tonsillar hypertrophy on Axis m. In contrast, Sleep Disorder Due to a General Medical Condition is appropriate if a general medical or neurological condition causes sleep-related s}'mptoms through a mechanism other than breathing disturbance. For instance, individuals with arthri tis or renal impainnent may complain of insomnia or hyp ersomnia, but this does not result from breathing impairment during sleep. The use of, or withdrawal from, substances (including medications) can produce insomnia or hypersomnia similar to that in Breathing-Related Sleep Disorder. A careful h istory is usually sufficient to identify the relevant sub stance, and foll ow-up shows improvement o f the sleep disturbance after discontinuation of the substance. In other cases, the use of a substance (e.g., alcohol. barbiturates, benzodiazepines, or tobacco) has been shown to be associated with Breathing-Related Sleep Disorder. An individual with symptoms and signs consistent with Breathing-Related Sleep Disord er should receive that diagnosis, even in the presence of concurrent substance use tha t is exacerbating the condition.
622
B. The disturbance is not better accounted for by anothe r mental disorder a nd is not due to the direct physiologica l eHects of a substance (e.g., a drug of abuse, a medica t ion) or another general medical condition (other than a breathi ng-related d isorder),
Coding note:
623
\Iancing the sleep-wake schedule in Delayed Sleep Phase Type. Prospective sleep wake diaries or sleep charts are often a useful adjunct to di agnosis.
Subtypes
Del ayed Sleep Phase Typ e. This type of Circad ian Rhythm Sleep Disorder is characterized by a delay o f circadian rhythms, including the sleep-wa ke cycle, relative to the demands of society . rvleas urement of end ogenous circadian rhythms (e.g., core body temperature, p lasma melatonin levels) during the individual's usual (i.e., delayed ) sleep-wa ke schedule reflects this d elay. Individua ls wi th this SUbty pe are h )'Pothesized to have an abnonnally d im inished ability to phase-advance sleep-wake hou rs (i.e., to move sleep and wakefulness to earlier clock times) o r an aHeration in the us ual alignment of sleep with other circadian rhythms. As a result, these individuals are "locked in" to habitually late sleep hours and have great difficulty shifting these sleep hours forwa rd to an earlier time. The circadian phase o f sleep is s table: indi\' id uals will fa ll asleep and awaken a t consis ten t, albeit d elayed, times when left to their ow n sched ule (e.g., on weekends or vacations). Affected individuals complain o f d ifficulty fallin g asleep at socially acceptable hou rs, but once sleep is initiated , it is normal. There is concomitant difficulty awakening at socially acceptable hours (e.g., multiple alarm clocks are often unable to arou se the individual). Many individuals w ith this disord er will be chronically sleep deprived as a res ult of the need to awaken for social and occupational obligations in the morning. Sleepiness d uring the desired w ake period may result. Jet Lag Type. In this type of Circadian Rhythm Sleep Disorder, the endogenous circadian sleep-wake cycle is no rmal and the disturba nce arises from conflict between the pattern of sleep and wakefulness generated by the ci rcad ian system and the pattern o f sleep and wakefulness req uired by a new time zone. Individuals with this type complain of a mis match between desired and required hou rs of sleep and wakefulness. The severity of symptoms is proportional to the number of time zones traveled, with ma ximal di ffi culties oft en noted after traveling through eight o r more time zones in less than 2-1 hours. Eastw ard travel (advancing Sleep-wake hours) is typ ically more d iffi cult for most individuals to tolerate than wes tward tra vel (delaying sleep-wake hours). Shift Work Typ e. In this t}'Pe of Circad ian Rhyth m Sleep Disorder, the end ogenolls circad ian sleep-wake cyd e is normal and the d is turbance arises from conflict between the pattern of sleep and wakefulness generated by the circadian system and the d esired p attern of sleep and wakefulness req ui red by shift work. Night-sh if t schedules (with s hi fting back to a day schedule on d ays off) and rota ting-sh ift schedules arc the most d isruptive becau se they force sleep and wakefulness into aberran t circad ian positions and prevent any conNorkers on these shifts ty pically have a s ho rter sleep dusis tent ad justment. I ration and more frequent dishubances in sleep continui ty than morning and afternoon workers. Conversel y, these indi viduals may feel sleepy or fall asleep during the desired wake period , that is, in the middle of the night work s hift. Work schedules tha t involve slowly rotating shifts o r rotations to progressively
624
307.45 Circadian Rhythm Sleep Disorder (formerly Sleep-Wake Sched ule Disorder)
625
workers, p articularly those who have sleep difficulties. Shift work is a ris k fac tor for sleepiness-related work and m otor vehicle accidents. The non-24-hour sleep-wake pattern has been described primarily in blind individuals, particularly those with no light perception (e.g., from retrolental fibroplasia or surgical enucleation) as opposed to those with some degree of conscious light perception . Napping and regularly recurring insonmia occur when the individual's endogenous circadian rhythms (which a re slightly longer than 24 hours) are out of phase with the light-dark cycle and socially appropriate sleep-wake hours. Individ uals with any Circadian Rhythm Sleep Disorder may u se increased amounts of alcohol, sedative-hypn otic, or s timulants in an attempt to control their inappropriately phased sleep-wake tendencies. The use of these subs tances may in tum exacerba te the Circadian Rhy thm Sleep Disorder. Delayed Sleep Phase Type has been associated with schizoid, schizotypal, and avoidant personality feahues, p articularly in adolescents, as well as with depressive symptoms and Depressive Disorders. "Non-24-hour sleep-wake pattern" and "irreg ular sleep-wake pattern" have also been associated with these same feahues. Jet Lag and Shift Work Typ es may precipitate or exacerba te a Manic or Major Depressive Episode or an episode of a Psychotic Disorder. Shift work is also associated with depressive symptoms. Associat e d laboratory findings . Sleep studies yield different results depending on what time they are performed. For individuals w ith Delayed Sleep Phase Type, s tudies conducted at the preferred sleep times will be essentially n ormal for age. However, when studied at socially nonnal sleep times, these individuals have prolonged sleep latency, reduced sleep efficiency (due mainly to sleep-onset di ffic ulties), short sleep duration, and, in some individuals, modera tely short REM sleep latency. Laboratory proced ures designed to measure the phase of the endogenous circadian pacemaker (e.g., core body temperature, plasma melatonin levels) reveal the exp ected phase delay in the timing of acrophase (p eak time) and nadir w hen individuals are studied during their usual sleep-wake times. In addition, awakening time may be d elayed relative to other circadian rhythms . When studied during their habitual workweek sleep hours, ind ividua ls w ith Shift Work Type usually have normal or short sleep latency, reduced sleep duration, and more frequent sleep continui ty dis turbances compa red w ith age-matched individuals with "normal" nocturnal sleep patterns. There may be a specific reduction in stage 2, stages 3 and 4, and REM sleep in many cases. Polysomnographic patterns in shift workers have been shown to remain stable over intervals of 2 years, s uggestin g neither adaptation nor worsening. Measures of physiological sleepiness, such as the Multiple Sleep La tency Test (MSLT), s how a high degree of sleepiness d u ring d esired wa ke times (e.g., during the nigh t shift). After a period of adj us tment to a normal diurnal schedu le, these indiv iduals have normal nocturnal sleep and nornlal levels of daytime sleepiness. ""hen studied on their usu al shift-work schedules in their usual environment, shift workers demons trate changes in the overt timing of their circadian rhythms relative to nonnal diurnal patterns. However, these changes seldom if ever result in a complete nocturnal orientation. Interventions s uch as bright light can shift endogenous circad ian rhythms into phase with the nig ht shift, but this does not necessarily improve subjective complaints or performance. N ight shift work may be associated with increases in triglyceride or ch oles terol levels.
626
Laboratory studies of simulated. jet lag demonstrate prolonged sleep latency, impaired sleep efficienc)" reductions in REM sleep, and minor reductions in slow-wave sleep. These features recover toward baseline values over 1-2 weeks and are more severe with simulated eastward travel (i.e., advanced s leep hours) than with simulated westward travel (Le., delayed sleep hours). Other laboratory measures, including circadi an rhy thms of melatonin, core body lempCrfl ture, alertness, and performance, also take several days or weeks to adjust foUowing simulated jet lag. Non-24-hour sleep-wake pattern in blind individuals is often characterized by "free-nmning" circadian rhythms of core body lemperah.lre, melatonin secretion, and sleep propensity. In o ther words, these rhythms have a period of slightly longer than 24 hours, similar to those of Sighted individuals deprived of all time cues in experimental settings. Ind ivid uals with "advanced sleep phase pattern," as expected, show earlier timing of endogenous circadian rhythms, as well as a shortening o f the endogenous circad ian rhythm period.
Associated physical examination findings and general medical conditions. No specific physical find ings are described for Circadian Rhythm Sleep Disorder. Shift workers may appea r haggard or sleepy and may have an excess of gastrointestinal disturbances, includ ing gastritis and peptic ulcer disease. The roles of caffeine and alcohol consumption and altered eating patterns h ave not been fully eva luated in these cases. Shift work has been associa ted " 'ith risk fac tors fo r ca rd iovascular disease, such as hypertens ion, "nondipping" 24-holl.f blood pressure patterns, increased atherogenic lipids, and abnormal electrocardiographic measures (prOlonged QTc interval). It may also be associated with a slightly increased risk for actual cardiovascular disease, a lthough not all studies have found this. Non-24-hour sleep-wake pattern often occurs in blind individuals, particularly those with no ligh t perception. Circadian Rhythm Sleep Disorder may exacerbate p reexisting general medical conditions.
Prevalence
The prevalence for any of the types of Circadian Rhythm Sleep Disorder has not been well established. Prevalence fi gures for the Delayed Sleep Phase Type from popula tion surveys have varied widely, ranging from 0.1 % to 4% in adults and up to 7".. in / /0 adolescents. Up to 600 of night shift workers may have Shift Work T}'p e.
307 .4 5 Circad ian Rhythm Sleep Disorder (fo rmerly Sleep-Wake Schedu le Disorder)
627
Cou rse
Delayed Sleep Phase Type typically begins duri.ng adolescence and may fol low a psychosocial stressor. Without intervention, Delayed Sleep Phase Type typically lasts for years or decades but may "correct" itself given the tendency for endogenous circadian rhythm phase to advance with age. Treatment can often normaljze sleep hours at least temporarily, but there is a persistent vulnerability for delayed sleep hours and other symptoms. Shift Work Type typically persis ts for as long as the individual works that particular scheduJe. Reversal of symptoms generally occurs within 2 weeks of a return to it normal diurnal sleep-wake schedule. Experimental and field data concerning jet lag indicate that it takes approx imately 1 day p er time zone traveled fo r the circadian system to resyndlionize itself to the new local time. Differen t circad ian rhythms (su ch as core body temperature, hormonal level. alertness, and sleep patterns) may readjust at different rates.
Familial Pattern
A family history may be present in up to 40% of individuals with Delayed Sleep Phase Type. A familial form of Advanced Sleep Phase Type, segregating as an autosomal dominant trait w ith high penetrance, h as been identified.
Differential Diagnosis
Circadjan Rhythm Sleep Disorder mus t be dis ting uished from normal patterns of sleep and normal adjustments following a change in schedule. The key to stich distinctions lies in the persistence of the d is turbance and the presence and deg ree of social or occupational impairment. For ins tance, many adolescents and yOlmg adults maintain delayed sleep-wake schedules, but w ithout di stress or interference wi th school or work routines. Likewise, many individuals characterize themselves as ei ther "nigh t owls" or " morning larks," because of their preference for either late or early sleep schedules. These tendencies in themselves do not w arrant a diagn osis of Delayed Sleep Phase Type or "ad vanced sleep phase pattern. " A diagnosis wou ld be made only in indi viduals who persistently experience clinically Significant distress or impairment and who have difficulty changing their sleep-wake pa ttern. Similarly, almost anyone who travels across time zones w i.\l experience transient sleep disn lption. TIle diagnosis of the Jet Lag Type should be reserved for indi\' iduals wi th associated severe sleep disturbances and work d is rup tion. Delayed Sleep Phase Type mllst be differentia ted from volitional p atterns of delayed sleep hours. Some individuals who voltmtarily delay sleep onset to participa te in social or work activi ties may complain of d ifficulty awakening . \<\lhen perm.itted to do so, these indi viduals fall asleep readily at earlier times and, after a period of recovery sleep, have no signifi cant difficulty awakening in the morning. In sllch cases, the primary problem is sleep deprivation rather than a Circadian Rhy thm Sleep Disorder. Other i.ndjviduals (pa rticularly children and adolescents) m ay volitionaUy shift sleep hours to avoid school or family demands. The pattern of difficulty a wakening vanishes when desired activities are sched uJed in the morning h ou rs. T a similar n
628
way, younger children in volved in limit-setting batt les w ith parents may p resent as
sufficien t evidence to exclude these other disorders. In some cases, other primar),
Sleep Disorders, stich as Breathing-Related Sleep Disorder or periodic lim b movements di sorder, may complicate Shift Work o r Jet L.1g Types. This possibility should be suspected when reversion to a normal diurnal schedule does not provide relief from sleep-rela ted symptoms. Olher types of Circad ian Rhythm Sleep Disorder, such as "non-24-hour sleep-wake pattern" and "irregular sleep-wake pattern," are distingu ished from the Delayed Sleep Phase Type by the stable pattern o f delayed sleepwake hours characteristic of the la tter. Patterns of delayed or advanced slee p th at occur exclu sive ly during another mental disorder arc not d iagnosed separately. Fo r instance, an ind ividual wi th Major Depressive Disorder may have d elayed sleep hours similar to those in Delayed Sleep Phase Type, but if this sleep pattern occurs only during the Major Depressive Episode, an addi tional diagnosis of Circadia n Rhythm Sleep Disorder would not be warranted. Likewise, an ind ividual exp eriencing an acute exacerbation of Sch izophrenia may have a very irregular sleep-wake pattern, but if this sleep pattern is only associated w ith the exacerbation, no additional diagnosis of Circad ian Rhythm Sleep Disorder would be made. Substances (including medications) can cause delayed sleep onset or awakening in the morning. For instance, consumption of caffeine or nicotine in the evening may delay sleep onset, and the use of hypnotic medications in the middle of the n ight may delay the time of awakening. A diagnOSis of Su bstance-Ind uced Sleep Disorder may be considered if the sleep d isturbance is judged to be a direct p hysiological consequence of regular substance use and warrants independent clinical attention (sec p. 655). General medica l conditions rarely cause fixed delays or advances of the sleepwake schedule and typically pose no difficulty in differen tial d iagnosis.
307 .47
629
Delayed Sleep Phase Type: a persistent pattern of late sleep onset and late awakening times, with an inabi lity to fall asleep and awaken at a desired earlier t ime Jet Lag Type: sleepi ness and alertness that occur at a n inappropriate time of day relative to local time, occurri ng after repeated t ravel across more than one t ime zone Shift Work Type: insomnia during the major sleep period or excessive sleepiness during the major awake period associated with night shift work or frequently changing shift work Unspecified Type
307.47
The Dyssonmia N ot Otherwis e Specified category is for insomnias, hypersonmias, or circadian rhythm disturbances that do not meet cr iteria for any s pecific Dyssomnia. Examples include
l. Complaints of clinically sign ificant insomnia or hypersomnia that are attribut-
able to e nvironmental fac tors (e.g., noise, light, frequ e nt interruptions). 2. Excessive s leep iness Ihal is attributable to o ngoing sleep depriva tion . 3. "Res tless legs syndrome" : nus syndrome is characterized by a desire to move the legs o r arms, associated with wlComfortable sensa tions typicall y descr ibed as creepi.ng, cra w ling, tingling, burning, or itdling . Frequent movements of the limbs occur in an effort to relieve the uncomfortable sensa tions. Symptoms are w orse when the individual is a t rest and in the e vening or night, and they are relieved temporarily by movement. The uncomfortable sensations and limb m ovements can delay s leep onset, a w aken the indi vidual from s leep, and lead to day time s leepiness or fatigue . Sleep s tudies de monstrate involuntary periodic limb movements during sleep in a majority of indi vid uals with restless legs syndrome. A minority of ind ivid uals ha ve e vidence of anemia or reduced serum
630
Sleep Disorders
iron stores. Peripheral nerve eJecrrophysiologicaJ s tudies and gross brain mor phology a re usuall y normal. Restless legs syndrome can occur in an idiopa thic form, or it can be associated with general medical or neurological conditions, including normal pregnall,}', renal failure, rheumatoid arthritis, peripheral vascu-
la r disease, or peripheral nerve dysflU1ction. Phenomenologically, the hvo forms are indistinguishable. The onset of restless legs syndrome is typically in the Sffand or third decade, alth ough up to 20% of ind ividuals w ith this syndrome may
have symptoms before age to. The prevalence of restless legs syndrome is be-tween 2% and 10% in the general population and as high as 30% in general medical populations. Prevalence increases with age and is equal in males and females. Course is marked by stability or worsening of symptoms with age. There is a positive family history in 50%-90% of indi viduals. The major differential diagnoses include medication-induced akathisia, peripher.l1 neuropa thy, and nochlrnalleg cramps. Worsening at night and periodic limb movements are more common in restless legs syndrome than in medication-induced akathisia or peripheral neuropathy. Unlike restless legs syndrome, nocturnal leg cramps do not present wi th the desire to move the limbs nor are there frequent limb movemen ts. 4. Periodic limb movements: Periodic limb movemen ts are repeated low-amplitude brief limb jerks, particularly in the lower extremities. These movements begin near sleep onset and d ecrease during stage 3 or 4 non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. lvtO\'ements usually occur rhythmically every 20-60 seconds and are associated w ith repea ted, b rief arousa ls. Ind ividuals are often unaware of the ach la l movements, but may complain of insomnia, frequent awakenings, or daytime sleepiness if the number of movemen ts is very large. Indiv idua ls may have consid erable variabil ity in the number of periodic limb movements from nig ht to night. Period ic limb movements occur in the majority of individuals with restless legs syndrome, but they may also occur w ithout the other sym p toms of restless legs synd rome. Indiv idua ls with normal pregnancy or with conditions such as renal failure, congestive heart failure, and Posttraumatic Stress Disorder may also develop periodic limb movements. Although ty pical age at onset and prevalence in the general population are unknown, periodic limb movements increa se with age and may occu r in more than one-third of individuals over age 65. Men are more common ly affected than wonlen. 5. Situations in which the clinician has concluded that a Dyssomnia is present but is unable to d eterm ine w hether it is primary, due to a general med ical cond ition, or substance induced.
Parasomnias
Parasomnias are disorders characterized by abnonnal behavioral or physiological events occurring in association wi th sleep, s pecific sleep stages, o r sleep-wa ke transitions. Unlike dyssomnias, parasomnias do not involve abnormalities of the mechanisms generating sleep-wake states, nor of the timing of sleep and wakefulness. Rather, parasomnias represent the activation of physiological systems at inappropriate times during the sleep-wake cycle. I.n particular, these disorders involve activation of the autonomic nervous system, motor system, or cognitive processes during
307 .47
sleep or sleep-wake transitions. Different parasomnias occur at different times during sleep, and specific parasomnias often occur during sp ecific sleep stages. Individuals with parasoJlmias usually present with complaints of unusu al behavior during sleep rather than complaints o f insomnia or excessive daytime sleep in ess. This section includes N ightmare Disorder, Sleep Terror Disorder, Sleepwalkin g Disorder, ,md Parasamnia Not Otherw ise Specified.
632
Associ at ed Featu res and Disorders
Sleep Di sorders
Associated descriptive features and mental disorders. In in d ivid uaJs w ith Nightmare Disorder, m ild au tonomic arousal (e.g ., sweating, tachycardia, tachypnea) may be evident on awakening. Individ uals who have had frequent nightmares since childhood tend to show elevated rales of general psychopatho logy on symptom measu res. Depressive and anxiety symp toms that do not meet criteria for a s pecifi c diagnosis are common among individ uals with N igh tmare Disorder. Bod y movements and vocalization a re not characteristic of N ightmare Diso rder because o f the loss of skeletal muscle tone that no rmally occurs during REM sleep. ' <\Then talking, screaming, or striking ou t do occur, these are most likely to appear as brief p henomena tha t terminate a nightmare. These behaviors are also more likely to occu r in the n igh tm ares that accompany Posttraumatic Stress Disord er, because these n igh tmares may occur during non- rap id eye movement (NREM) sleep.
Associate d laboratory findings . Polyso mnographic studies d emonst rate abru pt awakenings from REM sleep tha t correspond to the individual 's report o f nightmares. These awakenings usually occur d uring the second half o f the night. In most cases, the REM sleep episode will have lasted for more than 10 mi n utes and may include a greater-than-average number of eye m ovements. Heart rate and respiratory rate m ay increase o r show increased variability before the awakening. N igh tmares following tra umatic events (e.g ., i.n ind ividuals with Posttra umatic Stress Disorder) may arise during N REM sleep, particularly stage 2, as well as d uring REM sleep. Other p olysomnographic featu res, including sleep continu ity and sleep architecture, are not characteristically abnormal in N ightmare Disord er.
Preval ence
Between 10% and 50% of chi ldren ages 3-5 years have n ightmares of sufficient intensity to d isturb their paren ts. In the adult population, as many as 50% of individuals may report at least an occasional nightmare. In young adults, at least 3% report having nigh hllares frequently or always. However, the actual prevalence o f N ightmare Disord er is unknown.
307.47
633
Course
Nightmares often begin between ages 3 and 6 years. When the frequency is high (e.g., several per week), the dreams may become a source of concern and distress to both children and parents. Most child ren who develop a n ightmare problem ou tgrow it. In a minority, the dreams may persist at high frequency in to ad u lthood, becoming virtually a lifelong dishubance. Adults with chronic nightmares report similar degrees of subjective sleep d is turbance as those who have had nigh tmares for less than 6 months. A tendency toward amelioration of the disorder in later decades has been described.
634
Slee p Disorders
Type, may be considered (see p. 651). Alth ough nightmares may frequently occur during a d elirium, a separate diagnosis of N igh tmare Disorder is not given. N igh tm ares occu r frequently as part of oth er m ental disorders (e.g., Posttrauma tic
Stress Disorder, Schizophrenia, Mood Disorders. other Anxiety Disorders, Adjustment Disorders, and Personality Disorders). If the nightmares occur exclusively during the course of another mental disorder, the diagnosis of Nightmare Disorder is not given. Many individuals experience an occasional, isolated n ightmare. N ightma re Disorder is not diagnosed unless the frequency and severity of nightmares result in significant distress or impai rment.
Relati o nship to the Internati onal Cl ass ification of Sleep Disord ers
Nightmare Disord e r corrcsponds to the diagnosis of N ightmares in the International Classifica tion of Sleep Di sorders (ICSD).
Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frighten ing dreams, usually involving threats to survival, security, or self-esteem. The awakenings gene rally occur during the second half of the sleep period. and alert (in contrast to the confusion and disorientation seen in Sleep Terror Disorder and some forms of epilepsy).
B. On awakening from the frightening dreams, the person rapidly becomes oriented
C. The dream experience, or the sleep disturbance resulting from the awakening, causes clinically significant distress or impairment in social, occupational, or other importa nt areas of functioning .
D. The nightmares do not occur exclusively during the course of another mental disor-
der (e.g., a delirium, Posttraumatic Stress Disorder) and a re not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
307.46
Diagnost ic Fea t u res
The essential feature of Sleep Terror Disorder is the repeated occurre nce of sleep tcrrors, that is, abrupt awakenings from s leep usually beginning with a panicky scream or cry (Cri terion A). Sleep terrors u suaUy begin during the firs t third of the major sleep episode and last 1-10 m inutes. The episodes are accompan ied by au tonomic arousal and behavioral manifestations of inte nse fear (Crite rion (3). During an episode, the individual is d iffi cult to awaken or comfort (Crite rion C). If the i.ndhridual
307.46
635
awakens after the sleep terror, no dream is recalled, or only fragm en tary, single images are recalled. On awakening the following morning, the individual has amnesia for the event (Criterion D). TIle sleep terror episodes must cause clinically significant distress or impairment in social, occupational, o r other important areas of functioning (Cri terion E). Sleep Terror Disorder should not be diagnosed if the recurrent events are d ue to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a genera l medical condition (Criterion F). Sleep terrors are also called "n ight terrors" or pavor nocrumus. During a typica l episode, the individual abruptly sits up in bed screaming o r crying, wi th a frigh tened expression and au tonomic signs of intense anxiety (e.g., tachycardia, rapid brea thing, flushing of the skin, sweating, d ilation of the p upils, increased mu scle tone). TIle indiv idual is usually unresponsive to the efforts o f others to awaken or comfort h im or her. If awakened, the person is confused and disoriented fo r several minutes and recounts a vague sense of terror, usually withou t dream content. Although fragmentary vivid dream images may occur, a story like dream sequence (as in nightmares) is no t reported. Most commonly, the individual does not awaken full y, but returns to sleep, and has amnesia for the episode on awakening the next morning. Some individuals may vaguely recall ha ving an "episode" during the p revious night, but do not have detai led recall. Usually on ly one ep isode will occur on any one night, althou gh occasionally several episodes may occur at intervals throughout the night. For tile diagnosiS to be made, the individual must experience clinically significant distress or impairment. Embarrassment concerning the episodes can impair social rela tionships. Individuals may avoid siruations in which others might become awa re o f the disrurbance, such as going to camp, visiting friends overnight, or sleeping with bed partners.
636
Slee p Disorders
Associated laboratory f indings . Sleep terro rs begin during deep N REM s leep tha t is characterized by slow-frequency EEG acti vity (delta). This EEG activity is most prevalent during stages 3 and 4 N REM sleep, w hich are concen tra ted in the fi rst third of the major sleep episode. Therefore, sleep terrors are a lso most li kely to occur in the
firs t third of the night. However, episodes can occur d uring slow-wave sleep at an)' time, even during daytime naps. The onset of sleep terror episodes is typically heralded by very high voltage EEG delta activity, an increase in muscle tone, and a Iwofold 10 fourfold increase in heart ra te, oft en to over 120 beats per minu te. During the ep isode, the polysomnogram may be obscured w ith movement artifact. In the absence of such artifact, the EEG typically shows theta or alpha activity during the episode, indicating partial arousaL Individuals with Sleep Terror Disorder m ay also have abrupt arousals from deep NREM sleep that do not p rogress to full episodes of sleep terror. Such episodes can incl ude abru p t tach ycardia .
Associated physical e xamination findings and general m e dical conditions . Fever and sleep d eprivation can p roduce an increased frequ ency of sleep terror episodes.
Preva lence
There are limited d ata on Sleep Terror Disorder in the general popu lation. The p revalence o f sleep terror episodes (as op posed to Sleep Terror Disorder in which there is recurrence and d istress or impairment) has been estim ated at 10/ -6% among children 0 and at less than 1% of adults.
Co urse
Sleep Terror Disorder usually begins in child ren beh \'ccn ages 4 and 12 years and resolves s pon taneously d u ring adolescence. In adults, it m ost conunon ly begins beh \'een ages 20 and 30 years and often follows a chronic course, w ith the frequency and severity of episodes waxing and waning over time. The frequency of episodes varies both within and amon g individuals. Episodes usually occur at in tervals of days or weeks but m ay occur on consecu tive nights.
Familia l Pattern
Individ uals w ith Sleep Terror Disorder frequently report a positive family history of either sleep terrors or sleepwa lking. Some studies indicate ., l O -fold increase in the
307.46
prevalence of the disorder among first-degree biologica l relatives. The exact mode of . inheritance is unknown.
Differential Diagnosis
Many individuals suffer from isolated episodes of sleep terrors at some time in their lives. The d istinction behveen individual episodes of sleep terrors and Sleep Terror Disorder rests on repeated occurrence, intensity, clinically significant impairment or distress, and the poten tial for injury to self or others. Sleep Terror Disorder must be differentiated from other d isorders that produce complete or partial awakenings at night or unusual behavior during sleep. The most important differential diagnoses for Sleep Terror Disorder include N ightmare Disorder, Sleepwalking Disorder, other parasomnias (see Parasomnia Not Otherwise Specified), Breathing-Rela ted Sleep Disorder, and seizures occurring during sleep. In contrast to individuals with Sleep Terror Disorder, individuals w ith Nightmare Disord er typically awaken easily and completely, report vivid story like dreams accompanying the episodes, and tend to have episodes later in the night. The d egree of autonomic arousa l and motor activity is not as great as that in Sleep Terror Disorder, and recall is more complete. Sleep terrors usually occur during slow-wave sleep, whereas nighhnares occur during REM sleep. Parents of children w ith Sleep Terror Disorder may misinterpret reports of fearfulness and frag mentary imagery reports as nigh tmares. Sleepwalking Disorder may be difficult to differentiate from cases of Sleep Terror Disorder that involve prominent motor activity. In fact, the two disorders frequently occur together, and family history commonly involves both disorders. The p rotol)'Pical case of Sleep Terror Disord er involves a p redominance of autonomic a rousal and fea r, with a lesser degree of motor activ ity that tends to be abrupt and d isorganized. The prototypical case of Sleepwalking Disorder involves little autonomic arousal or fea r and a greater deg ree of o rganized motor activity. Parasomnias Not Othenvise Specified include several presentations that can resemble Sleep Terror Disorder. The most common example is " REM sleep behavior disorder," which also produces subjective fea r, violent moto r activity, and the potential fo r inju ry. Because this occurs during REM sleep, it involves vivid storylike dreams, more immediate and complete awakening, and motor activity that clearly follo ws dream content. "Nocturnal paroxysmal d ystonia " also includ es awakenings from sleep w ith motor activity, but this activity is longer in duration, more rhythmic and stereotyped , and not associated with subjective reports or signs of fear. Hypnagogic hallucinations, experienced sporadically by many otherwise-asymptomatic individuals, as weU as more regularly by those with Narcolepsy, may be associated with anxiety. Their occurrence at sleep onset, vivid images, and subjective sensation of wakefulness differentiate these episodes from sleep terrors. Ra rely, an individual wi th a Breathing-Related Sleep Diso rder may have episodes of awakenings associated w ith fear and panic tha t resemble those in Sleep Terror Disorder. The association with snoring, obeSity, and respiratory symptoms such as witnessed apneas, an inability to breathe, or choking episodes d istinguishes Brea thing-Related Sleep Disorder. A single episode of sleep terror can also occur during the slow-wave sleep rebound that follows the abrupt treahnent of obstructive
638
Sleep Disorders
sleep apnea syndrome (e.g., following nasal continuous positive airway pressure
[CPAPl therapy). Seizures that occur during s leep can produce s ubjective sensations o f fear and stereotyp ed behaviors. followed by confusion and difficulty awa kening. Most n octurnal seizures occur at s leep-wake transitions, but they may occur during s low-wave sleep. Incontinence and tonic-clonic movemen ts suggest a seizure disorder, bu t front al an d temporal lobe seizures can produce more complex beha viors as well. An EEG often reveals intericlal findin gs in individuals with s leep-reiated seizures, but EEG monitoring during nocturnal sleep may be needed for definitive differentia l diagnosis. Sleep disruption related to seizures should be diagnosed as Sleep Di sord er Due to a General Medical Condition, Parasom nia Type (see p . 651). Sleep Disord ers Due to a General Medical Condition other than sleep-related seizures may rarely cause unusual beha vioral episodes at night. The ne\\' onset o f abnormal behavior during sleep in a middle-aged or old er adult should prompt consideration of a closed head injury or centra l nervous system pa thology such as tumor or infection. Sleep terror episodes also may be exacerbated or induced by med ications sllch as central nervou s system depressants. If episodes are judged to be a di rect physiological effect of taking a medication or substance. the disorder should be classified as a Substance-Induced Sleep Disord er, Parasomnia Type (see p. 655). Panic Disorder may also cause abrupt awakenings from deep l\TR.EM sleep accompanied by fearfulness. but these episod es produce rapid and complete awakening without the confusion. anmesia. or motor activity ty pica l of Sleep Terror Disorder. lndi \' iduais who have Panic Attacks during sleep report tha i these symptoms are virtually identica l to those of Panic Attacks that occur during the day. The presence of Agoraphobia may also help d ifferentiate the two disorders.
307.46
Sleepwalking Disorder
639
sode . D. No detailed dream is recalled and there is amnesia for the episode. E. The episodes cause clinically significant distress or impairment in sodal, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological eHects of a substance (e.g., a drug of abuse, a medication) or a genera l medical condition.
307.46
Diagnostic Features
Sleepwalking Disorder
The essential feature of Sleepwalking Di sorder is repeated episod es of complex motor behavior initiated during sleep, including rising from bed and walking about. s lepwa lking episodes begin during slow-wave s leep and therefore mos t often occur during the first third of the night (Criterion A). During e p isodes, the indi"idual has reduced ale rtness and responsiveness, a blank stare, and relative unrespons iveness to conununication with others o r efforts to be a wakened by others (Criterion B). If a wakened during the episode (o r on awakening the foll owing morning), the ind ividual has limited recall for the eve nts of the episode (Criterion C). After the episode, there may initially be a brief period of confusion or difficulty orie nting, followed by fuU recovery o f cognitive function and appropriate behavior (Criterion D). The sleepwalking must cause clinically s ignificant dis tress or impairment in social, occupationa\, or other important areas of h.mctioning (Criterion E). SIepwalking Disorder should not be diagnosed if the beha vior is due to the d irect physiological effects of a s ubstance (e.g., a drug of abuse, a medication) or a ge neral medical condition (Crite rion F). Sleepwa lking episod es can include a varie ty of beha viors. In mild e pisodes (sometimes called "confus ional arousals"), the individual may simply sit up in bed , look about, or pick at the blanket or sheet. More typically, the individual achmlly ge ts out of bed and may walk into closets, out of the room, up and dow n stairs, and e ve n out of buildings. Individuals may use the ba throom, eat, and ta lk during episodes. Running and fra ntic attempts to escape some apparent threat can al so occur. Most behaviors during sleepwalking episodes are routine a nd of low complexity. H owever, cases of unlocking doors and even ope rating machinery have been reported . Particula rly in
childhood, sleepwalking can also include inappropriate behavior (e.g., urinating in a closet). Most episodes last fo r several minutes to a half hour. Sleepwalking episodes can terminate in spontaneous arousals followed by a b rief period of confusion, o r the indiv id ual may return to bed and continue to sleep until the morning. Not uncommonly, the individual may aw aken the next morning in another place, or with evidence o f having performed some activity during the night, but with complete amnesia for the event. Some episodes m ay b e followed by vague recall o f fragmenta ry d rea m images, bu t usually not by typical storylike d rea ms. During sleepwa lking episod es, ind iv iduals may talk o r even respond to others' questions. However, their articu lation is poor, and true d ialogue is rare. Individuals rna}' resp ond to o thers' requests to cease their acti vity and return to bed. However, these behaviors are performed w ith reduced levels of alertness, and awaken ing an in divid ual h om a sleep walking episode is typ ically very d ifficult. If aw akened, the individual remains confu sed fo r several minutes and then returns to a normal sta te of alertness. For the d iagnosis to be made, the indi vidual must experience clinica lly sign ificant d istress or impairment. Indiv idua ls m ay avoid sihla tions that w ould revea l their behavior to o thers (e.g., children m ay avoid visiting friends or going to summer camp; adults may avoid sleeping with bedpartners, goin g on vacation, or staying away from home). Social isolation or occu pational difficulties can result.
307.46
pear at the beginning of the episode. Most commonly, the EEG is obscured by movement artifact during the actual episode. Heart rate and respiratory rate may increase at the beginning of the episode. lllese findin gs may occur with a full sleepwalking episode or with a more m inor beha vioral event (such as a confusional arousal). Other polysomnographic findings may include an increased number of transitions out of stages 3 and 4 sleep and reduced sleep efficiency. Other polysom nographic findings may include an increased number of transitions out of stages 3 and 4 sleep, increased awakenin gs during N REM sleep, and reduced sleep efficiency. Sleep-stage architec ture may show an increase in NREM stages 3 and 4 sleep but is otherwise unremark able. Sleep apnea and periodic limb movements are seen in a minority of individuals with Sleepwalking Disorder.
Associated physical exam ination findings and general medical cond itions. Fe ver or sleep depriva tion can increase the frequency of sleepwalking episodes. Db structive sleep apnea syndrome, periodic limb m ovement disorder, and other disorders that produce severe disruption of slow-wave sleep can also be associated with sleepwalking ep isodes. An association has been noted between Sleepwalking Disord er and mig raine headaches, Na rcolepsy, and other neurological conditions in a subset of individua ls.
Prevalence
Beh\'een 10% and 30% of children have had at least one ep isode of sleepwalking, and 2%-3% sleepwalk often. The prevalence of Sleepwalking Di sorder (marked by repeated ep isodes and impairment or d istress) is much lower, p robably in the range of 10/ -5"/ . Epidemiological surveys repo rt the prevalence of sleepwalking episodes (not 0 0 Sleepwalking Disorder) to be 1.0%-7.0% among adults, with weekly to monthly episodes occurring in 0.5%-0.7%.
Cou rse
Sleepwa lking can occur at any time after a child is able to wa lk, bu t episodes most commonly occur for the first time beh\'een ages 4 and 8 years. The peak prevalence occurs at about age 12. Episodes ra rely occur for the first time in adults, although some associated behaviors such as nocturnal ea ting may beg in several years after the sleepwa lking itself. The onset of Sleepwalking Disorder in adults with no history of sleepwalking as ch ildren should p rompt a search for specific etiologies such as sub-
\ 642
Sl eep Disorde rs
sla nce use or a neurologica l condition . The majority of adults with Sleepwalking Disorder have a his tory of episodes d uring childhood as w ell . Sleepwalking in childhood usually disappea rs sp ontaneous ly during ea rly adolescence, typically by age 15 years. Less commonly, episodes may have a recurrent course, with return of episodes in early ad ulthood after cessation o f episodes in lale childhood . Sleepwal kin g Disord er in adults most often follows a chronic, waxing and waning course. Sleepwalking e pisodes may occur as isolated even ts in indi viduals o f a ny age, bu t the mos t common pa ttern is repeated episodes occu rring over a period of several years.
307.46
Sleepwalking Disorder. A small num ber of indi \,jdu als may have confusional arousals with motor activity tha t occur d uring both ' RE~'1 and REM sleep. The defi nitive diagnosis in such cases should be based on a carefu l eva luation of clinical, polysomnographic, an d other laboratory findings. A var iety of other behaviors ca n occm w ith partia l arOllsals from sleep. Confusio nal arousals resemb le sleep walking episodes in all respects except the actual movement out of the bed. "Sleep drunkenness" is a state in which the individual shows a prolonged transition from sleep to wakefulness in the morning. It may be difficult to arouse the individual, who may violently resist efforts to awaken him or her. Again, ambula tion o r other more complex behaviors disting uish Sleepwalking Disorder. However. both confusion al a rousals and sleep drunkenness may occur in individuals with Sleepwalking Disorder. Sl eep-related seizures can produce episodes of unusual behavior that OCClU only du ring sleep. The individual is unresponsive and is amnestic for the episode. Typically, sleep-rela ted ep ilepsy produces Illore stereoty pical, persevera tive, low-com plexity movements th an those in sleepwalking. In most cases, individuals with sleep-related epilepsy also have similar episodes d lUing wakefulness. The EEG shows features of epilepsy, includi ng paroxysmal activity d uring the episodes and interictal features at other times. However, the p resence of sleep-related seizures does not preclude the presence of sleepwalking episodes. Sleep-related epilepsy should be d iagnosed as Sleep Disorder Du e to General Medical Condition, Parasomni a Typ e (see p. 651). Sleepwalking can be induced by use of. or w ithdrawa l from, substances o r medications (e.g., alcohol. ben zodiazepines, opiates, cocaine, nicotine, antips),chotics, tricyclic an tidepressants, ch lora l hydrate). In SUdl cases, Substance-Indu ced Sleep Di sorder, Paraso mnia Ty pe, should be d iagnosed (see p. 655). Di ssociative Fugue bears superficial similarities to Sleepwalking Disorder. Fugue is ra re in children, typically begins when the individual is awake, lasts hours or days, and is not char,1cterized by d isturbances of consciousness. Sleepwalking must also be distillgujshed from Malingering or other voluntary behavior occurring during wakefulnes s, although in some cases such d istinctions may be d ifficult. FeatlUes that suggest Sleepwalking Disorder include a positive childhood history, low-complexi ty or stereotyped behavior d ming sleepwalking episodes, the absence of secondary gain to the individ ual from his or her nocturnal behav ior, and the p resence of typical polysonuwgraphic findin gs such as repeated arOllsa ls from NREM sleep. Furthermore, it may be d ifficult for the ind ividual to convi ncing ly cowlterfeit the appearance or behavior o f sleepwa lking tulder direct observation or in a video recording made in the sleep laboratory.
644
Sleep Disorders
Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode.
the efforts of others to communicate wit h him or her, and can be awakened only with great difficulty.
B. While sleepwalking. the person has a blank, staring face, is relatively unresponsive to
C. On awakening (either from the sleepwa lking episode or the nelct morning). the p er-
impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation).
E. The sleepwalking causes clinically signi ficant distress or impairment in social, occupational, or other important areas of functioning . F. The disturba nce is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a genera l medical condition.
307.47
The Parasonmia 'o t Otherwise Specified category is for disturbances that are characterized b y abno rmal behavioral or physiological events during sleep o r sleep-wake transitions, but that do not meet cri teria for a more specific Parasomnia. Examples indude 1. REM sleep behavior disorder: motor activity, often of a violent nature, that arises during rapid eye movement (REM) sleep. Unlike sleepwalking, these episodes lend to occur later in the night and are associated with v ivid dream recall. 2. Sleep paralysis: an inability to perfo rm voluntary movement during the transition behveen wakefulness and sleep. The episodes may occur at sleep onset (hypnagogic) or w ith awakening (hypnopompic). The episodes are usually associated w ith extreme anxiety and , in some cases, fear of impending death. Sleep paralysis occurs commo nly as an ancillary symptom of arcolepsy and, in such cases, should not be coded separately. 3. Situa tions in which the clinician has concluded that a Parasonmia is present but is unable to delemline whether it is primary, due to a general medical condition, or substance induced.
645 1
307.42 Insomnia Related to Another Mental Disorder 307.44 Hypersomnia Related to Another Mental Disorder
Diagnosti c Feat u res
The essential feature of Insomnia Related to Another Mental Disorder and H}'persomma Rela ted to Another Mental Disorder is the presence of either insomnia or h}'persomnia that is judged to be related temporall}' and causally to another mental disorder. Insomnia or H ypersomnia that is the direct physiological conseque nce of a substance is not included here. Such presentations would be diagnosed as Substance-Induced Sleep Disorder (see p. 655). Insomnia Related to Another Mental Disorder is charac terized by a complaint of difficulty falling asleep, frequent awakenings during the nigh t, or a marked feeling of n onres torative s leep that has lasted for at least 1 month a nd is associa ted with daytime fa tigue or impaired da}'time fun ctioning (Criterion A). Hypersomnia Rela ted. to Another Menta l Disorder is characterized by a complaint of either p rolonged nighttime s leep or repea ted daytime s leep epis odes for at leas t 1 month (Criterion A). In both Insomnia and Hypersomnia Related to Another Menta l Disorder, the sleep s}'mptoms cause significant dis tress or impair ment in social, occupational. or other important areas of functioning (Criterion B). The insomnia or hypersomnia is not better accoun ted for b}' ano ther Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sl eep Disorder, or a Parasomnia) and hypersomnia is not better accOlUlted for by an inadequa te amount of s leep (Criterion 0 ). The sleep dis turbance must not be due to the direct physiological effects of a s ubstance (e.g., a drug of abuse, a medication) or a general medical condition (Crite rion E). Sleep disturbances are common features of other mental disorde rs. An additional diagnOSiS of Insomnia or H ypersomnia Related to Another Mental Disorder is made only when the sleep d is turbance is a predominant complaint and is sufficie ntly severe to warrant independen t clinical aUention (Criterion C). Individuals with this type of insonmia or hypersomn ia usually focus on their sleep dis turbance to the exclusion of the symptoms characteristk of the related mental disorder, whose presence may become apparent only after specific and persis tent ques tioning . Not infrequently, they attribute their symptoms of mental disorder to the fac t that they have slept poorly. Many mental disord ers may a t times involve insomnia or hypersomnia as the pred ominant problem. Lndividuals in a r."lajor Depressive Epis ode or who have Dysthyling asleep o r s la ying asleep or early mic Disorder often complain of d ifficul ty faL morning awakening with inability to return to sleep. H ypersomnia Related to Mood Dis order is more often associated w ith Bipolar Mood Dis order, Most Recent Episode
646
Sleep Disorders
Depressed, or a Major Depressive Episode, Wi th Aty pical Features. Indivi duals with Generalized Anxiety Disorder often report difficulty fallin g asleep and may aw" ken with anxious ruminations in the middle o f the nig ht. Some individ uals with Panic Disorder have nocturnal Panic Attacks tha t can lead to insomnia. Significant insomnia is often seen during exacerbations of Schizophrenia and other PsydlOtiC Disorders but is rarely the predominant complaint. Other mental d isorders thaI may be related to insomnia include Adjus hnent Disord ers, Somatoform Disorders, and Personality Disorders.
307.42 307.44
Insom nia Rel ated to Another Me ntal Disorder Hypersomnia Re lated to Another Mental Disord er
647
Polysomnographic findings in Manic Episodes are si milar to those found in Major Depressive Episodes. In Schizophrenia, REM s leep is diminished early in the course of an acute exacerbation, with a gradual return toward norma l va lues as clinical status improves. REM la tency may be reduced . To tal sleep time is often severely diminished in Schizoph re nia, and s low-wave sleep is typica lly reduced during exacerbations. Individuals with Panic Disorder m ay have paroxysm al awa ke nings on entering s tages 3 and 4 NREM s leep; these awakenings are accompanied by tachycardia, increased respira lory ra te, and cognitive and emotional sympto ms with Panic Attacks. Most other me ntal disorders produce nonspecific patterns of sleep dis turbance (e.g., prolonged sleep latency or frequ e nt awakenings). Laboratory testing of daytime sleepiness by the Multiple Sleep Latency Test in individuals w ith H yp e rsomnia Related to Another Mental Disorder often shows normal or only mild levels of physiological sleepiness compared with individuals with Primary H ypersonutia or Na rcolepsy. Associated physical examination findings and general medical conditions. Individuals wi th Insonmia or Hypersomnia Related to Another Me ntal Disorder rna}' appear tired, fati gued, or haggard during rou tine examina tion. The general medical conditions associated with these Sleep Disorders a rc the same as those associated with the underlying mental disorder.
Preva lence
Sleep problems are extremely corrunon in all types of mental disorders, but there are no accurate es timates of the percentage of individuals who present primarily because of s leep dis ruption . Insomnia Related to Another Mental Disorder is the mos t frequent diagnosis (35%-50%) among individuals presenting to sleep disorders centers for evaluation of chronic insomnia. Hype rsomnia Related to Another Mental Disord er is a much less freq uent d iagnosis (fewer than 5%) a mong individuals evaluated fo r hypersollmia at s leep disorders centers.
648
Cou rse
Sleep
D i so(de (~
The course of Sleep Disord ers Related to Another Mental Disorder generally follows the course of the underlying mental disorder itself. The sleep dish.lrbance rna)' be one of the earliest symptoms to appear in individua ls who s ubsequently d evelop an associated mental disorder. Symptoms of insomnia or hypersonmia often fluctuate considerably over time. For many individuals with depression, particularly those treated with medica tions, sleep dis turbance may improve rapidly, o ften more quickly than other symptoms of the underlying mental disorder. On the other hand, other individu als have persis ten t or intermittent insomnia even after the o ther symptoms of their Major Depressive Disorder remit. Individuals with Bipolar Disorder often have d istinctive sleep-related symptoms depending on the nature of the curren t epi sod e. During Man ic Episodes, ind ividuals experience hyposonmia, although Ihey rarely complain about their inability to sleep. On the other hand, s uch individuals may have ma rked dis tress about hypersomnia during Major Depressi\fe Episodes. Individuals: with Psychotic Disorders most often have a notable worsening in sleep early during the course of an acute exacerbation, but then report improvement as psychotic symptoms abate.
Insom nia Relat ed t o Another M ental Disorder Hypersomnia Relat ed t o A n other Me nt al Disorder
the diagnosis w ould be ch anged from Insomnia or H ypersomnia Related to Another Mental Disorder to Prima ry Insomnia or Pri mary H ypersomnia. Insomnia or H ypersomnia Related to Another Mental Diso rder is not d iagnosed if the presentation is better accounted for by another Sleep Disorder (e.g., N arcolepsy, Breathing-Related Sleep Disorder, or a Parasomnia). Insomn ia or Hypersomnia Related to Another Mental Disord er must be djstingu ished from a Sleep D isord er Due to a General Medi cal Cond ition . The diagn osis is Sleep Disorder Due to a General Medical Condition when the sleep disturbance is judged to be a d irect physiological consequence of a speci fi c genera l med ica l condition (e.g., pheochromocytoma, hyperthy roid ism). This determination is based on history, laboratory fi ndings, and ph ysical examination (see p. 651 for further discussion). A Substan ce-lndu ced Sleep Disorder is distin guished from Insomnia or Hypersomnia Related to Another Mental Disorder by the fact that a substance (i.e., a drug of abuse, a med ication ) is judged to be etiolog ically related to the sleep d isturbance (see p. 655 for fur ther discussion). For example, insomnia that occurs o nl y in the contex t of heavy coffee consumption would be diagnosed as Caffeine-Induced Sleep Disorder, Insomnia Type. Sleep Disorders Related to Another Mental Disorder m ust be differentia ted from norm al sleep patterns, as well as from other Sleep Disorders. Although complaints of occasional insomnia or hypersomnia are common in the genera l population, they are not usuaUy accompanied by the other signs and symptoms of a mental d isord er. Transient sleep d istu rbances are common reactions to stressfu l li fe events and generally do not warran t a diagnosis. A separate d iagnosis of Insomnia or Hypersomnia Rela ted to Adjustmen t Disorder sho uld be considered only when the sleep disturbance is pa rticularly severe and prolonged .
1650
Sleep Disorders
Diagnostic criteria for 307.42 Insomnia Related to . .. [Indicate the Axis I or Axis /I disorder]
A. The predominant complaint is difficu lty in itiating or maintaining sleep, or nonrestarative sleep. for at least 1 month that is associated with daytime fat igue or impaired
daytime function ing.
B. The sleep disturbance (or daytime sequelae) causes <:Iinically significant d istress or impairment in social, occupation al, or other important areas of functi onin g.
C. The insomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Diso rder. Genera lized Anxiety Disorder, Adjustment Disorder With Anxi
et y) but is sufficientl y severe to warrant independent clinica l attention.
D. The disturbance is not better accounted for by another Sleep Disorder (e.g., Narcolepsy, Breathing-Re lated Sleep Disorder, a Parasomn ia). E. The disturbance is not due to the direct physio logical effects of a substa nce (e.g., a drug of abuse, a medication) or a general medical condition.
Diagnostic criteria for 307.44 Hypersomnia Related to ... [Indicate the Axis I or Axis /I disorder]
A. The predominant complaint is exce ssive sleepiness for at least 1 month as evidenced
by either prolonged sleep episodes o r daytime sleep episodes that occur a lmost da ily. B. The excessive sleepiness causes cl inically significant distress o r impai rment in social. occupational, or other important areas of functioning.
c.
The hypersomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Disorder, Dysthymic Disorder) but is sufficientl y seve re to warrant independent clinical attention.
D. The disturbance is not better a cco unted for by another Sleep Disorder (e.g ., Narcolepsy, Breathing -Related Sleep Disorder, a Pa rasomn ia) or by an inadequate amou nt of sleep. E. The disturbance is not due to the direct physiological effects of a substance (e.g . a d rug of abuse, a medication) or a general medi cal condition.
651
Subtypes
The subtyp es listed below can be used to indica te which o f the follow ing symp tom presentations pred ominates. The cl inical p resentation of the speci fic Sleep Disorder
652
steep Disorders
Due to a General Medical Condition may resemble thai of the ana logous primary Sleep Disorder. However, the full criteria for the analogous primary Sleep Disorder do not need to be met to assign a diagnosis of Sleep Disorder Due to a General Medical Condition.
Insomnia Type. This subty pe refers to a sleep complaint characterized primarily by difficulty fallin g asleep, difficulty mainta ining sleep, or a feeling of nonreslorative sleep. Hypersomnia Ty pe. This subtype is used when the predominant complaint is one of excessively long nocturnal sleep or of excessive sleepiness during waking hours. Parasomnia Type. This subtype refers to a sleep dis turbance characterized primarily by abnormal behavioral events that occur in association with sleep or sleep transitions. Mixed Type. This subtype should be u sed to d esignate a sleep problem due to a general medical condition characterized by multiple sleep sym p toms but no symptom clearly predominates.
7BO.xx
foUowing vascular lesions to the u pper bra in stem), endocrine conditions (e.g., hypoor hyperthyroidism, hypo- or hyp erad renocorticism), viral and bacteria l infections (e.g., hypersomnia related to viral encephalitis), coughing related to pulmonary disease other than sleep-related breathing cond itions (e.g., dU"onic bronchitis), and pain from musculoskeletal d isease (e.g., rheumatoid arthritis, fibromyalgia). General medical conditions in which hypersomnia may p resent as a core feature of the illness inelude myotonic dystrophy and Prader-Wi lli syndrome.
Differential Diagnosis
Sleep disturbances are extremely conunon in the context of a delirium; therefore, a separate diagnosis o f Sleep Disorder Due to a General Medical Condition is not given if the disturbance occurs exclusively during the course of the delirium . In contrast, a diagnosis of Sleep Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the sleep disturbance is a d irect etiological consequence of the pathological p rocess causing the dementia and the sleep disturbance is a prominent part of the clinical presenta tion. Sleep Disorder Due to a Genera l Medical Condition must be differentiated from expected disruptions in sleep patterns, primary Sleep Disorders, Sleep Disorders Related to Another Mental Disorder, and Substance-Induced Sleep Disorders. rvlan y individuals experience sleep di srupti on during the course of a genera l medi cal or neurological condition. In the majority of cases, such complaints do not merit an add itional diag nosis of a Sleep Disord er. Ra ther, a diagnosis of Sleep Disorder Due to a General Med ical Condition should be reserved fo r cases in w hich the sleep d ishlrbance is a very p rominent clinical feature, atypical symptoms are present, or the individual is sufficiently distressed by the sleep symptom or attendant impairment that specific treatment for this disturbance is required. Sleep Disorders Due toa General Medical Condition are characterized by symptoms simi lar to those in primary Sleep Disorders. The differentia l diagnosis rests not on specific symptoms but rather on the p resence or absence of a medical condition judged to be etiologically related to the sleep complaint. In the specific cases of Narcolepsy and Breathing-Related Sleep Disorder, the underlying etiology of the sleep d isturbance is asswned to be a general medical condition. However, in these two specific examples, the general med ical cond ition does not exist independent of sleep symptoms. For th is reason, these two disorders are included in the "Primary Sleep Disorders" section. Differentiating a Sleep Disorder Due to a General Medical Condition from Substance-Induced Sleep Di sorder can prove very di fficult. In many cases, ind ividua ls with a significant general medical condition often take medication for that condition; these medications in tu rn may cause sleep-related symptoms. For example, an ind ividual may have sleep d isruption rela ted to asthma. However, that indiv idual may also be treated with theophylline preparations, which in some cases can themselves cause sleep dish.!rbance. Differentiating a Sleep Disorder Due to a General Medical Condition from a Substance Induced Sleep Disorder o ften rests on chronology, response to treatment or discontinuation of medications, and longitudinal COllise. In some cases, concurrent d iagnoses of Sleep Di sorder Due to a General Med ical Condition and Substance-Induced Sleep Disorder may be approp riate. In cases in which a drug o f abuse is suspected to be the cause for the Sleep Disorder, a urine or
\ 654
Sleep Disorders
blood drug screen may help to differentiate this problem from a Sleep Disorder Due
to a General Medical Condition. If the clinician cannot determine whether the sleep dis turbance is primary, related to another menial disorder, due to a general medical condi tion, or subs tance induced, the appropriate diagnosis is Dyssomnia o r Parasomnia Not Otherwise Specified.
clinical attention . B. There is evidence from the history, physical examination, o r laboratory finding s that the sleep disturbance is the di rect physiological consequence of a general medica l condition.
C. The disturbance is not better accou nted fo r by another mental disorder (e.g., an Ad
justment Disorder in which the stressor is a serious medical illness). D. The disturbance d oes not occur exclUSively during the course of a delirium. E. The disturbance d oes not meet the criteria for Breathing-Related Sleep Disorder or Narcolepsy. F. The sleep disturbance causes clinically significant d istress or impairment in social, occupational, or other important areas of functioning.
Specify type:
.52 _ 54 _ 59 .59
Insomnia Type : if the predominant sleep disturbance is insomnia Hypersomnia Type: if the predominant sleep disturbance is hypersomnia Parasomnla Type: if the predominant sleep disturbance is a Parasomnia Mixed Type: if mo re than one sleep distu rbance is prese nt and none predominates
Coding note: Include the name of the general medical condition on Axis I, e.g., 780.52 Sleep Disorder Due to Chronic Obstructive Pulmonary Disease, Insomnia Type; a lso code the general medical condition on Axis III (see Appendix G fo r codes).
655
Sleep Disorders
lnsomnia Type. This subty pe refers to a sleep complaint characterized primarily by difficulty fa lling asleep, d ifficulty maintaining sleep. or a feeling of nonrestorati ve sleep. Hy persomnia Type. This subtype is used when the predominant complaint is one o f excessively long noctu rnal sleep or of excessive sleepiness during wakin g hours. Parasomnia Type. This subty pe refers to a sleep disturbance characterized primaril}' by abnormal behavioral events that occur in association with sleep or sleep-wake transitions. Mixed Type. This subtype should be used to designate a substance-i nduced sleep problem characterized by multiple types of sleep symptoms but no symptom dearly predominates. The contex t of the developmen t of the sleep symptoms may be indicated by usinl one of the foll owing specifiers: With Onset During Intoxication. This specifier should be used if criteria ar. met fo r intoxication with the substance and symptoms develop during the intoxication synd rome. With Onset During Withdrawal. This specifier should be used if criteria an met fo r withdrawal from the substance and the symp toms develop during, 0\ shortly after, a withdrawal syndrome.
Recording Procedures
The name of the Substance-Induced Sleep Disorder begins with the specifi c substance (e.g., aJcohoJ, methylphenidate, thyroxine) tha t is presumed to be ca using the sleep disturbance. The diagnostic code is selected from the listing of classes of substances p rovided in the criteria set for Substance-Induced Sleep Disorder. For substances that d o not fit into any of the classes (e.g., thyroxine), the code fo r "Other Substance" should be used. In addition, for medica tions prescribed at therapeutic doses, the specific medication can be indica ted by listing the appropriate E-code (see Appendix G). The name of the disorder (e.g., Caffeine-Induced Sleep Disorder) is fo llowed by the subtype indicating the predominant symptom presenta tion and the specifier indica ting the context in w hich the sym ptoms developed (e.g., 292.89 Caffeine- Induced Sleep Disorder, Insomnia Type, With Onset During Intoxication). When more than one substance is judged to playa significant role in the development of the sleep disturbance, each shou ld be listed separately (e.g., 292.89 Cocaine-lnduced Sleep Disorder, Insomnia Type, With Onset During Intoxication; 291.89 Alcohol-Induced Sleep Disorder, Insomnia Type, With Onset During Withdrawa l). If a substance is judged to be the etiological fac tor but the specific substance ordass of substance is tmknown, the category 292.89 Unknown Substance-Induced Sleep Disorder may be used.
Specific Substances
Substance-Induced Sleep Disorder most commonly occurs during intoxicati on with the following classes of substances: alcohol; amphetamine and related substances;
caffeine; cocaine; op ioids; and sedatives, hypnotics, and anxiolytics. Sleep disturbances are also seen less commonly with intoxication with other types of substances. Substance-Induced Sleep Disorder can also occur in association with withdrawa l from the following classes of substances: alcohol; amphetamine and related stimulants; cocaine; opio ids; and sedatives, hypnotics, and anxiolytics. Each of the Substance-Induced Sleep Disorders produces EEG sleep patterns that are associated with, but cannot be considered diagnostic of, the disorder. The EEG sleep profile for each substance is hlrther related to the stage of use, whether intoxication, chronic use, or withdrawal following disconti nuation of the substance.
Alcohol. Alcohol-Induced Sleep Disorder typ ically occurs as the Insomnia Typ e. During acute intoxication, alcohol ty pically produces illl immediate sedative effect, with increased sleepiness and reduced wakefulness for 3-4 hou rs. This is accompanied by an increase in stages 3 and 4 non- rapid eye movement ! REM) sleep and reduced rapid eye movement (REM) sleep during EEG sleep studies. Follow ing these initial effects, the individual has increased wa kefulness, restless sleep, and, often, vi vid and anxiety-laden dreams for the rest of the sleep period. EEG sleep stud ies show tha t, in the second h alf of sleep after alcohol ingestion, stages 3 and 4 sleep is reduced, wakefulness is increased, and REM sleep is increa sed. Alcohol can aggravate Breathing-Related Sleep Disorder by increasing the number of obstructive apnea events. With continued habitual use, alcohol continues to show a short-Jived sedative effect for several hours, followed by sleep continuity disruption for several hours. During Alcohol ,<\Iithdrawal, sleep is grossly disturbed. The individual typically has extremely disrupted sleep continuity, accompanied by an increase in the amount and intensity of REM sleep. This is often accompanied by an increase in viv id dreaming and, in the most extreme example, constitutes pari of Alcohol ""ithdrawal Delirium. After acute withdrawal, individuals who have chronically used alcohol may continue to complain of light, fragmented sleep for weeks to years. EEG sleep studies confirm a persistent deficit in slow-wave sleep and persistent sleep continui ty disturbance in these cases.
Amphetamines and related stimulants. Amphetamine-Induced Sleep Disorder is characterized by insomnia during intoxication and by hypersomnia during withdrawal. During the period of acute intoxication, amphetamine reduces the total amount of sleep, increases sleep latency illld sleep continuity di sturbances, increases body movements, and decreases REM sleep. Slow-wave sleep tends to be reduced . During withdrawal from chronic amphetamine use, individuals typically experience hypersomnia, with both prolonged nocturnal sleep dLUation and excessive sleepiness during the daytime. REM and slow-wave sleep may rebound to above baseline values. Multiple Sleep LatenC}' Tests (MSLTs) may show increased daytime sleepiness during the withdrawal phase as weU.
Caffeine. Caffeine-Induced Sleep Disorder typically produces insomnia, although some individuals may present with a complaint of hypersomnia and daytime sleepi ness related to withdrawal (see p. 764). Caffeine exerts a dose-dependent effect, with increasing doses causing increased wakefulness and decreased sleep continuity. Pol)'somnography may show prolonged sleep latency, increased wakefulness, and
658
Sleep Disorders
a decrease in slow-wave sleep. Consistent effecls on REM sleep have not been described. Abrupt wi thdrawal from chronic caffeine use can produce hypersomnia.
Some indiv iduals may al so experience hypersomnia between daytime doses o f caffein e, as the immediate s timulant effect wanes.
Cocaine. As with other stimulants, cocaine typica lly produces insonmia during
acute intoxica tion and h ypersomnia during w itJldrawaJ. During acu te intoxica tion, the total amount of sleep may be drastica lly reduced, w ith only shorl bouts of very dis rupted sleep. Conversely, w ithd rawal after a cocaine binge is often associated with extremely prolonged sleep duration .
659
Other substances . Other substances may p roduce sleep disturbances. Common examples include medications that affect the central or autonomic nervous systems (including adrenergic agonists and antagonists, dopamine agonists and antagonists, cholinergic agonists and antagonists, serotonergic agonists and antagonists, antihistamines, and co rticosteroids). Clinically, such medications are prescribed for the control of hypertension and cardiac arrhythmias, ch ronic obstructive pulmonary disease, gastrointestinal motility problems, o r inHamma tory processes .
Differential Diagnosis
Sleep disturbances arc commonly encountered in the context of Substance intoxication o r Substance Withdrawal. A diagnosis of Substance-induced Sleep Disorder should be made in stead of a diagnosis of Substan ce Intoxication or Substance With drawal only when the sleep disturbance is judged to be in excess of that usua lly associated w ith the intoxication or withdrawal syndrome and w hen the d isturbance is suffiCiently severe 10 warrant independent clmical attention. For example, insomnia is a characteristic fea hlre of Sedative, Hypnotic, or Anxiolytic Withdrawal. Sedative-, Hypnotic-, or Anxioly tic-lnduced Sleep Disorder should be d iagnosed instead of Sedative, Hypnotic, or Anxiolytic Withdrawal only if the msomnia is more severe than that usually encountered w ith Sedative, Hypnotic, or Anxiolytic \<\Iithdrawal and requires s pecial attention and treahllent.lf the substance-induced sleep disturbance occurs exclusively during the course of a delirium, the sleep distu rbance is considered to be an associated featu.re of the delirium and is not diagnosed sepa.ratel}'. In sub sta nce-induced presentations that contain a mi x of different types of symptoms (e.g., sleep, mood, and anxiety), the sp ecific type of Substa nce- Induced Disorder to be diagnosed depends on wh.ich type of symptoms predominates in the clin ical presentation. A Subslancelnduced Sleep Disorder is distinguished from a primary Sleep Disorder and from Insomni a or Hyp ersomnia Related to Anothe r Mental Disorder by the fact that a substance is judged to be etiologically related to the symptoms (see p. 655). A Substance-Induced Sleep Disorder d ue to a prescribed treatment for a mental disorder or general medic,1l condition must ha ve its onset while the person is receiving the medication (or du.ring withd rawa l, if there is a w ithdrawal syndrome associated with the medica tion). Once the treahnent is discontinued, the sleep disturbance wiJIusual ly remi t within days to several weeks (depending on the half-life of the substance and the presence of a withdrawal syndrome). However, as discussed above, some form of sleep problem can persist at decreasing intensity for months following Secla tive, Hypnotic, or Anxiolytic Withdrawal. With these exceptions, if symptoms persist beyond 4 weeks, other causes for the sleep disturbance shou ld be considered . Not infrequently, individua ls with a primary Sleep Disorder use medications or drugs of abuse to relieve their symptoms. if the clinician judges that the substance is playing a significant role in the exacerbation of the sleep disturbance, an additional d iagnosis of a Substance-Ind uced Sleep Disorder may be warranted. A Substance-induced Sleep Disorder and Sleep Disorder Due to a General Medical Condition can also be difficult to di stinguish. Both may produce similar symptoms of insomnia, hypersomnia, or (more rarely) a Parasomnia . Furthermore, many
660
Sleep Disorders
indiv iduals with general medical conditions that cause a sleep complaint are treated with medica tions that may also cause distu rbances in sleep. The chronology of symptoms is the most important factor in disting uishing between these h vo causes of sleep disturbance. For instance, a sleep disrurbance tha i clearly preceded the use of any medica tion for treatmen t of a general medical condition would suggest a diagnosis of Sleep Disorder Due to a General Medical Condition. Conversely, sleep symptoms that appear only after the ins titution of a particular merucation or subs tance would s uggest a Substance-Induced Sleep Disorder. In a similar way. a sleep dis turbance tha I appears during treatment for a general medical condition but that improves after the medication is discontinued s ugges ts a d iagnosis of Subs tance-Induced Sleep Disorder. If the clinician has ascertained that the distu rbance is due to both a general medical condition and subs tance u se, both diagnoses (i.e., Sleep Disorder Due to a General Medical Condition and Substance-L nduced Sleep Disorder) are g iven. WIlen there is insufficient evidence to determine w hether the sleep d is turbance is due to a substance (including a medication) o r to a general medical condition o r is primary (i.e., not due to either a s ubstance or a general medical condition), Parasomn ia Not Othenvise Specifi ed or Dysso mnia a t O then vise Specified wouJd be indicated.
induced. Evidence that the symptoms are better accounted for by a Sleep Disorder that is not substance induced might indude the fo llowing: the symptoms precede t he onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after t he cessation of acute withdrawa l or severe intoxication or a re substantially in excess of what would be expected given the type or amount of the substance used or the durati on of use; or there is other evi dence that suggests the existence of an independent non-substance-induced Sleep Disorder (e.g ., a history of recurrent non-subst ance-related episodes) . D. The disturbance does not occur exclusively during the course of a delirium. E. The sleep disturbance causes cl inically significant distress or impairment in soc ial. oc cupat ional, or other important areas of function ing . Note : This diagnosis should be made instead of a d iagnosis of Substance Intoxication or Substance Withdrawal only when the sleep symptoms are in excess of those usually associated with the intoxicat ion or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinica l attent ion.
661
(29 1.89 Alcohol; 292 .89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine; 292 .89 Opioid; 292 .89 Sedative, Hypnotic, or Anxiolytic; 292 .89 Other [or Unknow nl Substance)
Specify type:
Insomnia Type: if the predominant sleep disturbance is insomnia Hypersomnia Type: if the predominant sleep disturbance is hypersomnia Parasomnia Type : if the predominant sleep disturbance is a Parasomnia Mixed Type: if more than one sleep disturbance is present and none predominates
Specify if (see table on p. 193 for applicability by substance):
With Onset During Intoxication : if the criteria are met for Intox ication with the substance and the symptoms develop during the intoxication syndrome With Onse t During Withdrawal: if criteria are met for Withdrawal from the substa nce and the symptoms develop during, or shortly after, a withdrawal syndrome
the presentation of d isorders in o ther sections of the manual (e.g ., Subs tance-Related Disorders, Pa raphilia s, Antisocial Personality Disorder, Cond uct Disorder, Schizophrenia, and Mood Disorders may have fea tures that in vol ve p roblems of imp ulse control). The essential feat u re o f Imp ulse-Control Disord ers is the fai lure to resist an impulse, d rive, o r temptation to p erform an act that is harmfu l 10 the person or to others. For m ost of the disorders in this se<tion, the individu al fee ls an increasing sense of tension or arousal before comm itti ng the act and then exp eriences pleasure, gratifica tion, or relief at the time of committi ng the act. Following the act there may or may not be regret, self-reproach, or gu ilt. TIle following d isorders are includ ed in this section: Interm ittent Explosive Di sorder is characterized b y d iscrete episodes of fa ilure to resist aggressive impu lses resu lting in serious assaults or d estruction o f p rop erty. Klept om ania is characteri zed by the recurrent failtue to resist imp u lscs to steal objects not needed for persona l use or monetary value. Py ro mani a is characterized by a pattern of fire setting for p leasure, gra tifica tion, or relief of tension. Pathol og ical Gambling is characterized by recurrent and persistent maladapti vc gambling behavior. Tri ch otill omania is characterized by recurrent pulling ou t of one's hair for p leasure, g ratification, or relief of tension that resu lts in noticeable hair loss. Impul se-Control Disord er Not O th en vise Sp ecified is included for corling disorders o f imp ulse control th at do not meet the criteria for any o f the s pecifi c ImpuJseControl Disorders described above o r in other sections of the manual.
Th iS
section includes disorders of im pulse con trol that arc not classified as part of
312.34
663
664
out of proportion to any provocation or precipitating p sychosocial s tressor (Criterion B). A diagnosis of Intermittent Explosive Disorder is made only after other mental disorders tha t might account for episodes of aggressive behavior have been ruled out (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/ Hyperactiv ity Disorder) (Criterion C). The aggressive episodes a re not due to the direct physiological effects of a subs tance (e.g., a drug of abuse, a medication) or a general medical condi tion (e.g ., head trauma, Alzheimer' s disease) (Criterion C). TIle individual may describe the aggressive episodes as "spells" or "a ttacks" in which the explosive behavior is preceded by a sense of tension or arousal and is followed immediately by a sense of relief. Later the individual may feel upset, remorseful, regretful, or embarrassed about the aggressive behavior.
Prevalence
Reliable informa tion is lacking, but Intermitten t Explosive Disorder is apparently rare.
Course
Limited d ata are ava il able on the age at onset of Intermittent Explosive Disorder, b ut it appears to be from childhood to the early 20s. Mode of onset may be abrupt and without a prodromal period. The course of Intermitten t Explosive Disorder is variable, with the disorder having a chronic course in some individuals and a more episodic course in other individuals.
Familial Patte rn
Mood Disorders, Substance Use Disorders, Intermittent Explosive Disorder, and oth er impulse-Control Disorders may be more common among the first-degree relatives of indiv iduals with Intermittent Explosive Disorder than among the general population.
Differential Diagnosis
Aggressive behavior can occur in the context of many other mental disorders. A diagnosis of Intermittent Explosive Disorder should be considered only after all other disorders that are associa ted with aggressive impulses or behavior have been ruled ou t. If the aggressive beh av ior occu rs exclusively during the course of a delirium, a
Impulse-Control Disorders Not Elsewhere Classified diagnosis o f Intermittent Explosive Disorder is not given. Similarly, w he n the behavior develops as part of it dementia, a diagnosis of Intermittent Explosive Disorder is not made and the appropriate diagnosis is dementia with the specifier With Behavioral Disturbance. Intermittent Explosive Disorder should be distinguished from Per sonality Change Due to a General Medical Condi tion, Aggress ive T yp e, which is diagnosed when the pattem of aggressive episodes is judged to be due to the direct physiological effects of a diagnosable general medical condition (e.g., an individual who has s uffered brain injury from an automobile accident and subsequently manifests it change in personality characterized by aggressive outbursts). In rare cases, episodic violence may occur in individuals w ith epilepsy, especially of fronta l and temporal origin (partial complex epi lepsy). A ca reful history and a thorough neurological evaluation are helpful in making the determination. Note that nonspecific abnormalities on neurological examination (e.g., "soft s igns") and nonspecific EEG changes are compatible with a diagnosis of Intermittent Explosive Disorde r and only preempt the diagnosis if they are ind icative of a d iagnosable general medical condition . Aggressive outbursts mily also occur in association with Su bstan ce Intoxication or Substance Withdrawal, particularly associated w ith alcohol, phencyclidine, cocaine and other s timulants, barbitu rates, and inhalan ts. The clinician should inquire carefu11y about the nature and ex ten t of s ubs tance use, and a blood or urine drug screen may be informative. Intermittent Explosive Disorder should be dis tinguished from the aggreSSive or erratic behavior that can occur in Opp osition al Defiant D isorder, Con du ct D isorder, Antisocial Personality Disorder, Borderl ine Personality Disorder, a Man ic Episode, and Sc hizophrenia. If the aggressive behavior is better accounted for as a diagnostic or associated feature of another mental disorder, a separate d iagnosis of Intermittent Explosive Disorder is no! given . H owever, impuls ive aggression in individuals with Antisocial Personality Disorder and Borderline Personality Disorder can have s pecific clinical relevan ce, in w hich case both diagnoses may be made. For example, if an indi vidua l with an established diagnosis of Bord e rline Pe rsonali ty Disorder develops discrete episodes of failure to resist aggressive impulses resulting in serious physical or verbal assaultive acts or des truction of property, an additional diagnosis of Intermittent Explosive Disorder may be warranted. "Anger attacks"-sudden spells of anger associated with autonomic arousal (tachycardia, sweating, flushing) and fee lings of being out of control- have been described in individuals with Major Depressive Disorder and Panic Disorder. If these attacks occur only in the setting of a Major Depressive Episode or a Panic Attack, they should not count toward a diagnosis of Intermittent Explosive Disorder. H owever, if these anger attacks a lso occur a t times other than during Major Depressive Epi sodes or Panic Attacks, and meet the Intermi ttent Explosive Disorder criterion for serious assaultive acts, then both diagnoses may be given . Aggressive behavior may, of course, occur when no men ial disorder is present. Pu rposeful behav ior is dis tinguished from Intermittent Explosive Disorder by the prese nce of motivation and gain in the aggressive act. In forens ic se ttings, individuals may m alinger Intermitlent Explosive Disorder to avoid responsibility for their behavior. Anger as a normal reaction to specific life even ts or environmental situations also needs to be distinguis hed from the anger th at may occur as part of an
312.32
Kleptomania
667 /
aggressive episode in Intermittent Explosive Disorder, which occurs with little or no provocation.
312.32
Diagnostic Featu res
Kleptomania
The essential feature of Kleptomania is the recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value (Criterion A). The individual experiences a rising subjective sense of tension before the theft (Criterion B) and feel s pleasure, gra ti fication , or relief when committing the theft (Criterion C). The stealing is not committed to express anger or vengeance, is not done in response to a delusion or hallucination (Criterion D), and is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder (Criterion E). The objects are stolen despite the fact that they are typicall}' of little va lue to the indiv idua l, who could have a fforded to pay for them and often gives them awa}' or discards them. Occasionally the individual may hoard the stolen objects or surreptitiously return them . Although individuals with this disorder wi ll generally avoid stealing when immediate arrest is p robable (e.g., in full \!iew of a police officer), they u sually do not preplan the thefts or full y take into account the chances of apprehension. The stealing is done without assistance from , or collaboration with, others.
668
Nervosa), Personality Disorders, and o ther Impulse-Control Disorders. The disorder may cause legal, fami ly, career, and personal difficulties.
Prevalence
Kleptomania is a rare condition that appears to occur in fewer than 5% of identifiea shoplifters. Its prevalence in the general population is unknown.
Co urse
Age at onset of Kleptomania is variable. The disorder may begin in childhood , adolescence, or adulthood, and in ra re cases in late adulthood. There is little systematic in formation on the course of Kleptomania, but three typical courses have been dE' scribed : sp oradic with brief epi sodes and long periods of remission; episodic with protracted p eriods of stealing and p eriods of remission; and chronic with some deg ree of flu ctuation. The disorder may con tinue for years, desp ite multiple convictiol1." for shoplifting .
Fa milial Pattern
There are no controlled family history studies of Kleptomania. However, preliminary data suggest that first -degree relatives of ind ividuals w ith Kleptomania may ha\e higher rates of Obsessive-Compul sh'e Disorder than the gen eral population.
Differential Diagnosi s
Kleptomania should be distinguished from ordinary acts of theft or shoplifting. Ordinary theft (whether planned or impulsive) is d eliberate and is motiva ted by the usefulness of the object or its monetary worth . Some individuals, esp l'CiaUy adolescents, may also stea l on a dare, as an act of rebellion, or as a rite of passage. The diagnosis is not made unless other characteri stic features of Kleptomania are also p resent. Kleptomania is exceedingly rare, whereas shoplifting is relatively common. In Malingering, individuals may simulate the symptoms of Kleptomania to a void criminal p rosecution . Antisocial Personality Disord er and Conduct Disorder arc distil' gUished from Kleptomania by a general pattern of antisocial behavior. Kleptomani. should be distinguished from intentional or inad vertent stealing that may OCC\lr dur ing a Manic Episode, in response to delusions or hallucinations (c.g., in Schizophreni a), or as a result of a d ementia.
312.33
Pyromania
669
D. The stealing is not committed to express anger o r vengeance and is not in response to a delusion or a hallucination . E. The steal ing is not better account ed for by Conduct Disorde r, a Manic Episode, or Antisocial Personality Disorder.
312.33
Diagnostic Features
Pyromania
The essential feahlre of Pyromania is the presence of multiple episodes of de Jibe r.1te and purposefu l fire setting (C riterion A). Individuals with this disorder e xperience tension o r affective a rousal before setting a fire (Criterion B). There is a fa scination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphemal ia, uses, consequences) (Criterion C). Indiv iduals with this disorder are often regular "wa tchers" at fires in their neighborhoods, may set off fal se alarms, and derive pleasure from institutions, equipment, and personnel associated with fire. They may spend time at the local fire department, set fires to be affiliated wi th the fire department, or even become fire fi ghters. Individuals w ith this disorder experience pleasure, g ratification, or a release of tension when setting the fire, w itnessing its effects, or participating in its afterma th (Cri terion D). The fire setting is not done for monetary gain, as an expression of sociopolitica l id eology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, or in response to a delu sion or a hallu cina tion (Criterion E). TIle fire setting does not result from impaired judgment (e.g., in dementia or Mental Retardation). 111e di,1gnosis is not made if the fire setti ng is better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder (Criterion F).
670
Preva lence
Pyromania is apparently rare.
Cou rse
There ace insu ffic ient data to esl"blish a typical age at onset of Pyromania. The relationship between fire setting in childhood and Pyromania in adulthood has no t been documented . In ind ividuals with Pyromania, fire-setting inciden ts are episodic and may wax and wane in frequency. Longitudinal course is lmknown .
Pyroma nia. Intentional fire setting rna}' occur for p ro fit, sabotage, or revenge; to conceal a crime; to make a pol itical sta tement (e.g., an act of terrorism or protest); or to attract attent ion or recognition (e.g., setting a fire in order to discover it and save the day). Fire setting may also occur as part of developmental experimentation in ch ildhood (e.g., playing with matches, lighters, or fire). Some indiv iduals with mental disorders u se fire setting to communica te a desire, wish, or need, o ften directed at gaining a ch ange in the nahlre or loca tion of services. This for m of fire setting has been referred to as "communicative arson" and mus t be carefully distinguis hed from Pyromania. A separate diagnosis of Pyromania is not given when fire setting occurs as part of Cond uct D iso rder, a Manic Episode, or Antisoci al Perso nality Disorder, or if it occurs in response to a delusion o r a hallucination (e.g., in Schizoph renia) or if it is due to the direct phYSiolog ical effects of a general medical condition (e.g., epilepsy). The d iagnosis of Pyromania s hould also not be given when fire setting results from impai red judgment associated w ith dementia, Men tal Retardation, or Substance Intoxication.
671
ology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in dementia, Menta l Retardation, Substance Intoxication).
f.
The fire setting is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder.
312.31
Diagnostic Featu res
Pathological Gambling
The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior (Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling behavior is better accounted for by a Manic Episode (Criterion B). The individual may be preoccupied with gambling (e.g., reliving pas t gambling experiences, planning the next gambling venture, o r thinking of ways to get money with which to gamble) (Cri terion Al). Mos t individuals with Pathological Gambling say that they are seeking "action " (an aroused, euphoric s tate) or excitement even more than money. Increasingly larger bets, or greater ris ks, may be needed to continue to produce the desired level of excitement (C riterion A2). Individuals with Pathological Gambling often continue to gamble d esp ite repeated efforts to control, cut b.1(k, o r stop the behavior (Criterion A3). There may be restlessness or irritability when attempting to cut down or s top gambling (Criterion A4). The individual may gamble as a way of escaping from problems or to relieve a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (C riterion AS). A pattern of "dlasing" one's losses may develop, with an urgent need to keep gambling (often with larger bets or the taking of grea ler ris ks) to undo a loss or series o f losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although all gamblers may chase fo r short period s, it is the long-term chase that is more characteristic of individuals with Pathological Gambling (Cri terion A6). The individual may lie to famil y members, therapis ts, or others to conceal the extent of involvement with gambling (Criterion A7). When the individual's borrowing resources are
1672
strained, the person may resort to antisocial behav io r (e.g., forgery, frau d, theft, or embezzlement) to obtain money (Criterion A8). The individua1 may have jeopardized or lost a significant relationship, job, o r educational or career opportunity because of gambling (Criterion A9). The individu al may also engage in "bailout" behavior. turning to fam ily or others fo r help with a des perate financial situati on that was ca used by gambling (Criterion AIO).
312.3 1
673
Gamblers Anonymous. Th is may be a function of the greater s tigma attached to female gamblers.
Prevalence
TIle p reva lence of Pathological Gambling is influenced by both the availa bility of gambling and the dura tion of availa bility such that with the increasing availability of legalized gambling, there is an increase in the prevalence of Pathological Gambling. Community studies estima te the lifetime prevalence of Pathological Gambling to range from 0.4% to 3.4% in adults, although prevalence rates in some areas (e.g., Puerto Rico, Austra lia) have been reported to be as high as 7%. Higher prevalence rates, ranging from 2.8% to 8%, have been reporled in adolescents and college s tudents. The prevalence of Pa thologicaJ Gambling may be increased in treatment-seeking individuals with a SubstanC Use Disorder. e
Course
PatholOgical Gambling typically begins in early adolescence in males and later in life in females. Although a few individuals are "hooked" with their very first bet, for most the course is more insidious. There may be years of social gambling followed by an abrupt onset thai may be precipitated by greater exposure to gambling or by a stressor. The gambling pattern may be regular or episodic, and the course of the disorder is Iypically ch ronic. There is generally a progression in Ihe frequency of gambling, the amount wagered, a nd the preoccupation w ith gambling and obtaining money w ilh wh ich to gam ble. The urge to gamble and gambling activity generally increase during periods of stress or d e pression.
674
gambling. these manic-like features dissipate. Problems with gambling may occur in individuals with Anti social Personality Disorder; if criteria are met for both disorders, both can be diagnosed.
is preoccupied with gambling (e.g., preoccupied with re living past gambling experiences. handicapping o r planning the next venture, or thinking of ways to get money with which to gamble) sired excitement has repeated unsuccessful efforts to control, cut back, or stop gambling is restless or irritable when attempting to cut down or stop gambling gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) after losing money gambling, often returns another day to get even ("chasing one's losses) lies to fami ly members, therapist, or others to conceal the exte nt of involvement with gambling has committed illegal acts such as forgery, fraud, theft, o r embezzlement to finance gambling has jeopardized or lost a significant relationship, job, or educational or career opportunity because o f gambling relies on others to provide money to rel ieve a desperate financial situation caused by gambling
(2) needs to gamble with increasing amounts of money in order to achieve the de-
(3)
(4) (5) (6)
(7) (8)
(9)
(10)
312.39
Diagnostic Feat ures
Trichotillomania
The essential featu re of Trichotillo mania is the recurrent pulling out of one's own hair that resu lts in noticeable hair loss (Criterion A). Sites of hair pulling may include any region of the body in w hich hair may grow (including axillar)" pubic, and perirectal regions), with the most common sites being the scalp,eyebrows, and eyelashes. Hair puU ing may occur in brief episodes scattered throughout the day or in less frequent bul more sus tained periods that can continue for hou rs. H air pulling o ften occurs in states of relaxa tion and dis traction (e.g., when reading a book o r watching television ) but may also occur during stressful circums tances. An increasing sense of tension is present immediately before pulling out the hair (Criterion B). For some, tension does not necessarily precede the act but is associa ted with attempts to resist the w ge. There is gratification, pleaswe, or a sense of relief when pulling out the hair (Criterion C). Some
312.39
Trichotilloman ia
individuals experience an "itchlike" sensation in the scalp that is eased by the act of pulling hair. The diagnosis is not given if the hair pulling is better accounted for by another menta l disorder (e.g., in response to a delusion or a hallucination) or is due to a general medical condition (e.g., i.nflammation of the skin or other dermatological conditions) (Criterion D). The d isturbance must cause Significant d istress or impairment in social, occupational, or other important areas of functioning (Crilerion E).
676
Prevalence
systematic data are available on the p revalence of Trichotillomania. Although Trichotillomania was previou sly thought to be an uncom mon condition, it is now believed 10 occur more frequen tly. For example, a s urvey of college studen ts found a lifetime ra le of 0.6%.
'0
Course
Transient periods of hair pulling in early childhood may be considered a benigl "habit" w ith a self-limi ted course. Individ uals who present with chronic Trichotillomania in adulthood often report onset in early adolescence. Some individuals have continuous sym p toms for decades. For others, the disorder may come and go for weeks, months, or }'ears at a time. Sites of hair pulling may vary over time.
Differential Di agnosis
Other causes of alopeci a shou ld be considered in indi vidua ls who d eny hair pulling (e.g., alopecia areata, male-pattern baldness, chronic discoid lupus erythematosus, lichen pianopilaris, folliculiti s decalvans, pseudopeJade, and alop ecia mucinosa). A separate diagnosis of Trichotillomania is not given if the behavior is better accounted for by another mental disord er (e.g., in response to a delusion or a hallucination in Schizophren ia). The repetiti ve hair pulling in TridlOtillomania must be distinguished from a compulsion, as in ObsessiveCompulsive Disorder. In ObsessiveCompulSive Disorder, the repetitive behaviors are performed in response to an obsession, or according to rules that mus t be applied rigidly. An additional diagnOSis of Stereotypic MO\'ement Disorder is not made if the repetiti ve behavior is limited t hair p ulling. The self-induced alopecia in Tricho tillomania mus t be dis tinguishe from Factitious Disord er With Predominantly Physical Signs and Symptoms, in w hich the m ot iva tion for the behavior is assuming the sick role. Many individuals twist and play with hair, especially during sta tes of heightened anxiety, bu t this behavior does not us ually quali fy for a diagnosiS of Trichotillomania. Some individuals may p resent with fea tures of Trichotillomania, but the resulting hai.r damage may be so slight as to be virtually undetectable. In s uch situations, the d iagnosiS should only be considered if the ind ivid ual experiences significant dis tress. In children, self-limited period s of hair pulling are common and may be considered a tempora ry "habit. " This form of childhood hair pulling differs from adult forms of Trichotillomania in that there may be an absence of reported tension or relief associated with the hair pulling. Therefore, among children, the d iagnosis should be reserved for situations in which the behav ior has p ersisted for several months.
-~
312.30
B. An increasing sense of t e nsion immediately before pulling out the hair or when attempting to resist the behavior.
C. Pleasure, gratification, or relief when pull ing out the hair.
D. The disturbance is not better accounted fo r by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition). E. The disturbance causes cl inically significant distress or impairme nt in social, occupational, or other important areas of functioning .
Adjustment Disorders
Diagnostic Features
The essential feature of an Adjustment Disorder is a psychological response to an
identifiable stressor or stressors that results in the development of clinically significant
might be considered normal or expectable can still qualify for a diagnosis of Adjustment Disorder if the reaction is s ufficiently severe to cause significant impairment.
This category s hould not be used if the disturbance meets the criteria for another specific Axis I disorder (e.g., a specific Anxiety or Mood Disorder) or is merely an exacerbation of a preexisting Axis I or 11 disorder (Criterion C). However, an Ad jus tment Disorder may be diagnosed in the presence of another Axis I or Axis II disorder if the latter does not account for the pattern of symptoms that have occurred in response to the stressor. The diagnosis of an Adjustment Disorder also d oes not apply when the symptoms represent Bereavement (Criterion D). By definition, an Adjus hnent Disorder mus t resolve within 6 months of the termination of the stressor (or its consequences) (Criterion E). However, the symptoms may persist for a prolonged period (i.e., longer than 6 months) if they occur in res ponse to a c1uonic s tressor (e.g., a chronic, djsabling genera l medical condition) or to a s tressor that has enduring consequences (e.g., the financial and emotional difficulties resulting from a divorce). The s tressor may be a single event (e.g., termination of a romantic rela tions hip), or there may be multiple s tressors (e.g., marked business difficu lties and marital problems). Stressors may be recurrent (e.g., associated with seasonal business crises) or continuous (e.g., Ijving in a crime-ridden neighborhood). Stressors may affect a single individual, an entire family , or a larger group or community (e.g., as in a natural disaster). Some stressors may accompany specific developmental events (e.g., going to school, leaving the parental home, getting married, becoming a parent, failing to attain occupational goals, retirement).
Subtypes a nd Specifiers
Adjustment Disorders are coded according to the subtype that best characterizes the predominant symptoms: 309.0 With Depressed Mood. This subtype should be used when the predominant manifes tations are symptoms s uch as depressed mood, tearfulness, or feeling s of hopelessness.
679
1 680
Adjustment Disorders
309.24 With Anxiety. This subtype should be used when the predominant manifes tations a re symptoms such as nervousness, worry, or jitteriness, or, in children, fears o f separation from major attachment figures. 309.28 With Mixed Anxiety and Dep ressed Mood. This subtype should be u sed w hen the p redominan t manifesta tion is a combination of d epression and
anxiety.
309.3 This SUbtype should be used when the predominant manifestation is a distu rbance in conduct in which there is viWith Dis turbance of Condu ct.
olation of the rights of others or of major age-appropria te societal norms and rules (e.g., truancy. vandalism, reckless driving, fighting, defaulting on legal responsibilities). 309.4 With Mixed Disturbance of Emotions and Conduct. This subtype should be used when the predominant manifestations are both emotional symptoms (e.g., depression, anxiety) and a d istu rbance of conduct (see above subtype). 309.9 Unspecified . This subtype should be used for maladaptive reactions (e.g., physical compla ints, social withdrawal, or work or academic inhibition) to stressors that are not classifiable as one of the specific su btypes of Adjustmen t Disorder.
The duration of the symptoms of an Adj ustment Disorder can be indicated by dlOOSing one of the following specifiers: Acute. This specifier can be used to indic.l te persistence of symptoms for less than 6 months. Chronic. This specifier can be used to indicate persistence of symptoms for 6 mon ths or longer. By d efinition, symptoms cannot persis t for more than 6 months after the termination of the stressor or its conseq uences. TIle Chron ic specifier therefore applies w hen the duration of the d istllTbance is longer than 6 months in response to a chron ic stressor or to a stressor that has enduring consequences.
Adjustm e nt Disorde rs
681
cal patients. The presence of an Adjustmen t Disorder may complica te the course of illness in indiv iduals who have a general medical condition (e.g., decreased compliance with the recommended medical regimen or increased length of hospital stay).
Preva lence
Adjustment Disorders are apparen tly comm on, although prevalence rates vary widely as a function of the population studied and the assessment method s used . The pre\'alence of Adjushllent Disorder has been reported to be between 2% and 8% in community samples of child ren and adolescents and the eld erly. Adjustment Disorder has been diagnosed in up to 12% of general hospita l inpatients who are referred fo r a mental health cons ul tation, in 10%- 30% of those in mental health outpatient settings, and in as many as 50% in specia l populations that have experienced a s pecific stressor (e.g., (oUowing cardiac surgery). Individuals from disadvantaged li fe circum stances experience a high rale of stressors and may be al increased risk for the disorder.
Course
By definition, the d isturbance in Adju stment Disorder begins within 3 months of onset of a stressor and lasts no longer than 6 months a ft er the stressor or its consequences have ceased. If the stressor is an acute event (e.g., being fired from a job), the onset of the d is tmbance is usually immedia te (or within a few days) and the dura tion is relatively brief (e.g., no more than a few months). If the stressor or its consequences perSist, the Adjustment Disorder may also persist. The persistence of Adjustment Disorder or its progression to other, more severe mental d isorders (e.g., Major Depressive Disorder) ma y be more likely in children and adolescents than in adults. However, some or all of this increased risk may be attribu table to the presence of comorbid conditions (e.g ., Atten tion-Deficit/ Hyperacti vity Disorder) or to the possibility that the Adjustment Disord er actually represented a subclinical prodrome manifestation of the more severe men tal disorder.
682
Adjustment Disorders
cme Axis I disorder. For example, if an individual has symptoms that meel criteria for
a Major Depressive Episode in response to a stressor, the diagnosis of Adjustment Disorder is not applicable. Adjustment Disorder can be diagnosed in addition to another Axis I disorder on ly if the latter does not accoun t for the pa rticular symptoms that occur in reaction to the stressor. For example, an individual may de\'elop Adjustment Disorder \o\' ilh Depressed Mood after los ing a job and at the same time ha ve a diagnosis of Obsessive-Compulsive Disorder. Because Personali ty Diso rders <ITe frequently exacerbated by stress, the addi tional diagnosis of Adjus tment Disorder is us ually not mad e. However, if symptoms that are no t characteristic of the Personality Disorder appear in response toa stressor (e.g., a person with Pa ranoid Personality Disorder d evelops depressed mood in response to job loss), the additional diagnosis of Adjustment Disorder may be appropriate. The diagnosis of Adjustment Disorder requires the p resence of an iden ti fiab le stressor, in contrast to the atypical or subthreshold p resen tations that would be diagnosed as a No t Othenvise Specified disorder (e.g., Anxiety Disorder Not Othenvise Specified). If the symptoms of Adjustment Disorder persist for more than 6 months after the stressor or its consequences have ceased, the diagnOSis should be changed to another mental disorder, usua lly in the appropriate Not Oth envise Specified ca tegory. Adjustment Disorder, Posttraumatic Stress Disorder, and Acute Stress Disorder all require the presence of a stressor. Posttraumatic Stress Disorder and Acute Stress Disorder are characterized by the presence of an extreme stressor and a specific constellation of sym p toms . In contrast, Adjustmen t Disorder can be triggered by a stressor of any severity and may involve a wide range of possible symptoms. In Psychological Factors Affecting Medical Condition, spedfic psychologica l symptoms, behaviors, or other factors exacerbate a gen eral medical condition, complicate treatment for a general medical condition, or Olhenvise increase the risks of developing a general medic.ll condition . In Adjustmen t Disorder, the relationsh ip is the reverse {i.e., the psychologica l symptoms develop in response to the stress of having or being diagnosed with a general medical condition}. Both condi tions may be present in some individuals. Bereavement is generally diagnosed instead of Adjustment Disorder when the reaction is an expectable response to the death of a loved one. The diagnosis of Adjustment Disorder may be appropriate when the reaction is in excess of, or more prolonged than, w hat would be expected. Adjustment Disorder should also be distinguished from other non pathological reactions to stress that do not lead to marked d istress in excess of wh at is expected and that do not ca use significant impairment in socia l or occupational functioning. Adjustment Disorder should not be diagnosed when the symptoms are due to the direct physiological effects of a General Medical Condition (such as the u sual transienl functional impairment thaI is associated w ith a course of chemotherapy).
683
disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. D. The symptoms do not represent Bereavement. E. Once the stressor (or its consequences) has term inated, the symptoms do not persist for more than an additional 6 months.
Specify if: Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months or longer
Adjustment Disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV. 309.0 309.24 309.28 309.3 309.4 309.9 With Depressed Mood With Anxiety With Mixed Anxiety and Depressed Mood With Disturbance of Conduct With Mixed Disturbance of Emotions and Conduct Unspecified
Personality Disorders
ThiS
section begins w ith a general definition of Personality Disorder that applies to each of the 10 specific Personality Disorders. A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to dis tress or impairment. The Personality Disorders included in this section are lis ted below . Paranoid Personality Disorder is a pattern of distrus t and suspiciollsness such that others' motives are in terpreted as malevolent. Schizoid Personality Disorderis a patte rn of detachment from social relationships and a restricted range of emotional expression. Schizotypal Personality Disorder is a pattern of acute d iscomfort in close relationships, cognitive or perceptual dis tortions, and eccentricities of behavior. Antisocial Personali ty Disorder is a pattern of disregard for, and v iolation of, the rights of others. Borderline Personality Disorder is a pattern of ins tability in interpersonal relationships, self-image, and affects, and marked impulsivity. His trionic Personality Disorder is a pattern o f excessive emotionality and attention seeking. Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empa thy . Avoidant Personality Disorder is a pattern of social inhibition, feelin gs of inadequacy, and hypersensitivity to negative evaluation. Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of. Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control. Personality Disorder N ot Othenyise Specified is a category provided fo r two situations: 1) the individual's personality pattern meets the general criteria for a Personality Disorder and traits of several different Personality Disorders are present, but the criteria for any specific Personality Disorder are not met; or 2) the individual's personality pattern meets the general criteria for a Personality Disorder, but the individual is considered to have a Personality Disord er that is not included in the Classification (e.g., passive-aggressive personality d isorder) . The Personality Disorders are grouped into three clusters based on descriptive similarities. Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C
685
686
Personality Disorders
includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. lndiv iduals with these disorders often appear anxious or fearfu l. It should be no led that this clus tering system, although useful in some research and ed ucational s ihlc1nons, has serious limitations and has not been consisten tly va lidated . Moreover, ind ividuals frequently present with co-occurring Personality Disorders from different clusters.
687
When an Axis I disorder is not the principal d iagnosis or the reason fo r visit, the clinidan is encouraged to ind icate w hich Personality Disorder is the principal diagnosis or the reason for visit by noting " Principal Diagnosis" or "Reason for Visit" in parentheses. In most cases, the principal diagnosis or the reason for visit is also the main focus of attention or treatment. Personality Disorder Not O ther wise Specified is the appropriate d iagnosis for a "mixed" presentation in which criteria are not met for any single Personality Disorder b ut fea tures of several Personality Disord ers arc present and involve clinica lly s ignificant impClirment. Specific maladaptive personality traits that do not meet the threshold for a Personality Disorder may also be listed on Axis U. In SUcil ins tances, no specific code should be used; for examp le, the clinician might record "Axis 11: V71.09 No diagnosis on Axis U, histrionic personali ty traits. " The use of particular defense mechanisms may also be indicated on Axis U. For example, a clinician might record " Axis II: 301.6 Dependent Personality Disorder; Frequen t use of deniaL" Glossary definitions for specific defense mechanisms and the Defensive Flmctioning ScClle appear in Appendix B (p.807). When an individu al has a chronic Axis I Psychoti c Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder (e.g., Sch izotypal, Schizoid, Paranoid), the Personality Disorder should be recorded on Axis n, followed by " Premorbid" in parentheses. For example: Axis I: 295.30 Schizophrenia, Paranoid Type; Axis n : 301.20 Schizoid Personality Disorder (premorbid).
688
Personality Disorder
Certain Personality Disorders (e.g., Antisocial Personality Disorder) are diagnosed more frequently in men . Others (e.g., Borderline, His trionic, and Dependent Personalit) Disorders) are diagnosed more frequently in women. Although these differences in prevalence probably reflect rea l gender differences in the presence of such patterns, clinicians mus t be cau tious not to overd iagnose or underdiagnose certain Personality Disorders in femal es or in males because of socia l stereotypes about typical gender roles and behaviors.
Course
TIle features of a Personality Disorder usually become recogltizable during adolescence or early adult life. By definition, a Personality Disorder is an enduring pattern of think ing, feeling , and behaving that is relatively stable over time. Some types of Personality Disorder (notably, Antisocial and Borderline Personality Disorders) tend to become less evident or to remit with age, whereas this appears to be less tnle for some other typ es (e.g., Obsessive-Compulsive and Schizotypal Personality Disorders).
Differential Diagnosis
Many of the specific criteria fo r the Personality Disorders d escribe feature s (e.g., suspiciousness, dependency, or insensitivity ) that are also characteristic of episodes of Axis I men ial disorders. A Personality Disorder should be diagnosed only wh en the defining characteristics appeared before early adulthood, are typical of the individual's long-term nmctioning, and do not occur excl usively during an episode of an Axis I d isorder. It may be particularly difficult (and not particularly u seful) to distinguish Personality Disorders from those Axis I disorders (e.g., Dysthymic Disorder) that have an early onset and a chronic, relatively stable course. Some Persona lity Disorders may have a "spcctrum" relationship to particular Axis I cond itions (e.g., Schizotypal Personality Disorder with Schizophrenia; Avoidant Personality Disorder with Social Phobia) based on phenomenological or biological simi larities o r familial aggregation. For the three Personality Disorders that may be related to the Psychoti c Disorders (i.e., Paranoid , Schizoid, and Schizotypal), there is an exclusion criterion stating that the pattern of behavior must not have occurred exclusively d uring the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder. When an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder, the Personali ty Disorder should also be recorded, on Axis II, foDowed by "Premorbid" in parentheses. The clinician must be ca utious in djagnosing Personality Disorders du ring an epi sode of a Mood Disorder o r an Anxiety Disorder because these conditions may havf cross-sectional symptom features that m imic persona li ty traits and may make it mOrl difficult to evalua te retrospecti vely the individual 's long-term patterns o f functioning. When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Posttraumatic Stress Disorder should be considered (see p . 463). When a person has a Substance-Related Disorder, it is important not to make a Personality Disorder d iagnosis based solely on behaviors that are consequences of Substance Intoxication or Wi thdrawal or that are associated with
6S9
activities in the service of s us ta ining a dependency (e.g., antisocial behav ior). When enduring changes in personality arise as a res u lt of the direct physiological effects of a general medical condition (e.g., brain tumor), a diagnos is of Personality Change Due to a General Medical Con dition (p. 187) should be considered. Personality Disorders mus t be distingui shed from personality traits that do not reach the th reshold for a Personali ty Disord er. Personality trai ts are diagnosed as a Persona lity Disorder only when they are inflexible, maladaptive, and persis ting and cause significant functional impairment or subjective dis tress.
the expectations of the individual's culture. This pattern is manifested in two (or more) of the foll owing areas:
(1) cognition (i.e., ways of perceiving and int erpreting self, other people, and
events) (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
(e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
1 690
p roach is to d escribe more specific areas of personality d ysfun ction , including as many as 15-40 d imensions (e.g., a ffecti ve reactivity. social apprehensiveness, cognitive dis tortion, impulsivity, insincerity, self-centeredness). Other dimensional models that h ave been p roposed include positive affecti vity , nega tive affectivity. and cons traint; novelty seeking, rewa rd d ependen ce, harm avo id ance, persistence, self-
directedness, cooperativeness. and self- transcendence; power (dominance "5. submission) and affiJi ation (love "s. hate); and pleasure seeking versus pain avoidance, passive accommoda tion versus active modification, and self-propagation versus o ther nurturance. The DSM-IV Personality Disorder clu sters (i.e., odd-eccentric, dramatic-emotionaL and anxious-fearfu l) may also be viewed as dimensions representing sp ectra of person ali ty dysfun ction on a continuum with Axis I mental d isorders. The alternative d imensional models share much in common and together appear to cover the impo rtant areas of personali ty d ysfun ction. Their integration, clinica l u tility, and relationship with the Personality Disorder diagnostic ca tegories and various asp ects o f personality dysfunction are under active inves tigation.
301.0
Diagnosti c Features
The essential fea ture of Paranoid Personality Disord er is a p allern of pervasive distrust and suspiciousness of o thers such that their motives are interpreted as m alevolent. This pattern begins by early adulthood and is present in a va riety of con texts. Individuals with th is d isorder asswne that other people will exploit, harm, or deceive them, even if no ev id ence exists to support this exp ectation (Criterion AI ). They suspect on the basis of li ttle or no evidence th at o thers a re p lotting again st them and may a ttack them suddenly, at any time and w ithout rea son. They often feel tha t they have been d eep ly and irreversibly injured by another person o r persons even when there is no objective evidence for this. They are preoccupied with unjustified d oubts about the loyalty or trustworth iness of their friends an d associates, whose actions are mi nutely scrutin ized for evidence of h ostile inten tions (Criterion A2). Any p erceived d eviation from trustworthiness or loyalty serves to support their underlying assu mptions. They are so amazed when a friend or associate shows loyalty that they cannol trust or believe it . It they get into trouble, they expect that fri ends and associates wil either a ttack or ignore them . lnd ividuals with this d isorder are relu ctant to confide in or become close to other becau se they fear that the informa tion they share w ill be used against them (C riterio; A3). They may refuse to answer personal q uestions, saying th at the info nnation is "nobody's business." They read hidden meanin gs that a re d emeaning and threa tening in to benign remarks o r even ts (Criterion A4). For example, an individual w ith this d isorder may misinterpret an honest m istake by a store clerk as a deliberate attempt to Shortchange or may view a casual hu morous remark by a co-worker as a serious
301.0
691
character attack. Compliments are often m isi nterpreted (e.g., a compliment on a new acqu isi tion is m.isinterp reted as a criticism fo r selfishness; a compliment on an accomplishment is misinterpreted as an attempt to coerce more and better performance). They may view an offer of help as a criticism that they are not doing well enough on their own. Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion AS). ~li.no r slights arouse major hostility, and the hostile feelings persist for a long time. Because they are constantly vigilant to the hannful intentions of o thers, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way. They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals with this d isorder may be pathologically jealous, often suspecting that their spouse or sexual pa rtner is unfaithful without any adequ ate ju stification (Criterion A7). They may ga ther trivial and circumstantia l "evidence" to support their jealous beliefs. They want to maintai n complete control of intimate rela tionships to avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and fidelity of their spouse or partner. Paranoid Personality Disorder sh ould not be d iagnosed if the pattern of behavior occurs exclusively d uring the course of Schizophrenia, a Mood Disorder With Psychotic Fea tures, or another Psychotic Disorder or if it is due to the direct physiological effects of a neurolog ical (e.g., temporal lobe epilepsy) or other general medical condition (Criterion B).
692
dis tinct from their own. Attracted by simplis tic formulations of the world, they are
often wary of ambiguous situations. They may be perceived as "fanatics" and form tightly knit "cults" or groups w ith others who share their paranoid belief systems.
Particularly in response to s tress, individuals with this disorder may experience very brief psychotic episodes (lasti ng minutes to hours). In some instances. Pa ranoid
Personality Disorder may appear as the premorbid antecedent of Delusional Disord er or Schizophrenia. Individuals w ith this d isorder may d evelop Major Depressive Disorder and may be at increased risk for Agoraphobia and O bsessive-Compulsive Disorder. Alcohol and other Substance Abuse or Dependence frequently occur. TIle most common co-occurring Personality Disorders appear to be Schizotypa l, Schizo id, Narcissistic, Avoidant, and Borderline.
Preva lence
The prevalence of Paranoid Personality Disorder has been reported 10 be 0.5%-2.5% in the genera l popu lation, 10%-30% among those in inpatient psychiatric settings, and 2%- 10% among th ose in outpatient mental health clinics.
Differenti al Diagnosis
Paranoid Personali ty Disorder can be distinguished from De lusional Disord er, Persecutory Type, Schizophren ia, Paranoid Type, and Mood Disorder With Psych otic
301 .0
Features because these disorders are all characterized by a period of persistent p sychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of Parruloid Persona lity Disorder, the Perso nality Disorder m~l s t ha ve been p resent before the onset o f psycho tic symptoms and must persist when the p sychotic symploms are in remission. \o\'hen an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by Paranoid Personality Disord er, Paranoid Personality Disorder shou ld be recorded on Axis II, follow ed by " Premorbid" in parentheses. Paranoid Personality Diso rder must be distinguished from Personalily Change Due to a Gene ral Medical Co ndition, in which tJle traits emerge due to the d irect effec ts of a general m edical condition on the central nervous system. It must also be dis tinguished from symptoms that may develop in association with chronic sub stance use (e.g., Cocaine-Related Disorder Not Otherwise Specified). Finally, it must also be distinguished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment). Other Personality Di sorders may be confused w ith Paranoid Personality Disorder because they have certain featu res in common. It is, therefore, important to distinguish among these d isorders based on d ifferences in their characteristic fea tures. However, if an individual ha s personality features tha t meet criteria for one or more Personality Disorders in addition to Paranoid Personali ty Disorder, all can be diagnosed. Paran oid Personality Disorder and Schizotypal Personality Disorder share the tra its of suspiciousness, interpersonal aloofness, and paranoid ideation, but Schizotypal Personality Disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and odd thinking and speech. Individ uals with behaviors that meet criteria for Schizoid Personality Disorder are o ft en perceived as strange, eccentric, cold , and a loof, but they d o not usually have prom inen t paranoid ideation. The tendency of indi viduals with Paranoid Personality Disord er to react to minor stimuli with anger is also seen in Borderline and Histrioni c Personality Disorders. However, these disorders are not necessarily associa ted w ith pervasive sus piciousness. People w ith Avoidant Personality Disorder may also be reluclant to confide in others, but mo re because of a fear of being embarrassed or found inade quate than fro m fear of others' malicious in tent. Although antisocial behavior may be presen t in some indiv idua ls wi th Paranoid Personality Disorder, it is not usually motivated by a desire for personal gain or to exploit others as in Antisocial Personali ty Diso rder, but rather is more often due to a desire for revenge. Individuals with Narcissistic Personality Disorder may occaSionally dis p lay suspiciou sness, social withdrawal, or alienation, bu t this d erives primarily from fears of having their imperfections or fl aws revealed . Paranoid traits may be adaptive, particularly in threaten ing environments. Para~ noid Personality Diso rder should be diagn osed only wh en these traits are in fl exible, maladaptive, and persisting ruld cause sig nificant ftm ctional impairment or subjective distress.
694
(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates (3) is reluctant to confid e in others because of unwarranted fear that the information will be used maliciously against him or her
(4) reads hidden demeaning or threatening mean ings into benign remarks or
events (5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights (6) perceives attacks on his o r her character or reputation that are not apparent to others and is quick to react angrily or to counterattack (7) has recurrent suspicions, without justification, regarding f idelity of spouse or sexual partner B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychot ic Features, or anot her Psychotic Disorder and is not d ue to the direct physiological effects of a gene ral medical conditio n.
Note: If criteria a re met prior to the onset of Sch izophrenia, add " Premorbid, " e.g., "Paranoid Personality Disorder (Premorbid). "
301.20
695
no close friends or confidants, except possibly a first-degree rela tive (C riterion AS). Individuals w ith Schizoid Personali ty Disorder often seem indifferent to the approva l or criticism of others and d o not appea r to be bothered by wh at others may think of them (Criterion A6). They may be oblivious to the normal subtleties of social intemction and often do not respond appropria tely to socia l cues so that they seem socially inept or superficial and self-absorbed . They usually d isplay a "bland" exterior without visible emotional reactivity and rarely reciprocate gestures or facial expressions, such as sm iles or n od s (Criterion A7). They cla im that they ra rely experience strong emotions such as anger and joy. They often d isp lay a constricted affect and appear cold and aloof. However, in those very unusual circumstances in which these individua ls become at least temporarily comfortable in revealing themselves, they may acknowledge having painful feelings, particularly related to social interactions. Schizoid Personality Disorder should not be diagnosed if the pattern of behavior occurs excl usively during the course of Schizophrenia, a Mood Di sorder With Psychotic Featu res, another Psychotic Disorder, or a Pervasive Developmental Disorder or if it is due to the d irect physiological effects o f a neurological (e.g., temporal lobe epilepsy) or other general medical cond ition (Criterion B).
696
w ith solitariness, poor peer relationships, and underachievement in school, which mark these children or adolescents as different and make them subject to teasing.
Schizoid Personality Disorder is diagnosed slightly more often in males and may cause more impairment in them .
Prevalence
Schizoid Personality Disorder is u ncommon in clinica l settings.
Differential Diagnosis
Schizoid Personality Disorder can be distinguis hed from Delus ional Disord er,
Schizophrenia, and Mood Disorder With Psychot ic Features because these disorders are aU characterized by a period of persistent p sychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of Schizoid Personality Disorder, the Personality Disorder must have been present before the onset of psychotic symptoms and must persist when the p sychotic symptoms are in remission. When an indiv idual has a chronic Axis ' Psychotic Disorder (e.g., Schizophrenia) that was preceded by Schizoid Personality Disorder, Sch izoid Personality Disorder should be recorded. on Axis Il followed by " Premorbid" in pa rentheses. There may be great difficulty d ifferentiating ind ividuals w ith Schizoid Personality Disorder from those with milder forms o f Autistic Disorder an d from those w ith As perger's D isorder. Milder fo mls of Autistic Disorder and Asperger' s Disorder are differentiated by more severely impaired social in teraction and stereotyped behaviors and interests. Schizoid Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge d u e to the direet effeets of a general medical condition on the central nervous system . It must also be distinguished from symptom s that may d evelop in association with ch ronic substance use (e.g., Cocaine-Rela ted Disorder Not Otherwise Specified). Other Personality Disorders may be confused w ith Schizoid Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on d ifferences in their characteristic features. H owever, if an individual has persona li ty features tha t meet criteria for one or more Personality Disorders in addition to Schizoid Personality Disorder, all can be diagnosed . Although characteristics of social isolation and restricted affectivity are common to Schizoid, Schizotypal, and Paranoid Personality Disord ers, Sch izoid Personality Disorder can be distinguished from SchizotypaJ Personality Di sorder by the lack of cognitive and perceptual distortions and from Paranoid Person ality Disorder by the lack of suspiciousness and paran oid ideation. TIle social isolation of Schizoid Person al ity Disorder can be d istinguished from that of Avoidant Personality Disorder, which is due to fear of being embarrassed or found inadequate and excessive antid
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pation of rejection. In contras t, people with Schizoid Personality Disorder have a more pervasive detachment and limited desire for social intimacy. Individuals with Obsessive-Com pulsive Personality Disorder may also show an apparent social detachment s temming from devotion to work and discomfort w ith emotions, but they do have an underlying capacity for intimacy. ind ividuals who are "loners" may display personality traits that might be considered schizoid . Only w hen these traits a re inflexible and maladaptive and ca use significant flU1ctional impainnent o r subjective distress do they cons titute Schizoid Personality Disorder.
B. Does not occur exclusively during the course of Sch izophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder. or a Pervasive Developmental Disorder and is not due to the direct physiol ogical effects of a general medical condition. Note: If criteria are met prior to the onset of Schizophrenia. add "Premorbid," e.g ., ~ Schizoid Personality Disorder (Premorbid)."
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Diagnosti c Features
The essential feature of Schizot)'pal Personality Disorder is a pen'asive pattern of social and in terpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual d istortions and eccentrici ties o f behavior. This pattern begins by early adulthood and is present in a variety of contexts. Individua ls with Schizo!")'pa! Personal ity Disorder often ha ve ideas of reference (i.e., incorrect interpretations of casual incidents and external events as having a particu lar and unus ual meaning speci ficall y for the person) (Criterion A 1). These should be dis tinguished fro m delusions o f reference, in which the beliefs are held with delusiona l conviction. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their s ubculture (Criterion A2).
Personality Disorders They may feel that they have special powers to sense events before they happen or to read others' thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse's taking the dog oul for a walk is the d irect result of thinking an hour earlier it should be done) or indirectly through compliance with magical rituals (e.g., walking pas t a specific object three times to avoid a certain harmful outcome) . Perceptual alterations may be p resent (e.g., sensing that another person is present or hearing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, bu t without actual derailment or incoherence (Criterion A4). Respon ses can be either overly concrete or overly abstract, and words or concepts are sometimes applied in unusual ways (e.g., the person may s tate that he o r sh e was not "talkable" at work). Individuals w ith this d isorder are often s uspicious and may h ave paranoid idea tion (e.g., believing their colleagues at work a re intent on underm ining their reputation with the boss) (Criterion AS). They are u sually not able to negotiate the hl ll range of affects and interpersonal cuing required for successful relationships and thus often appear to interact with others in an inappropriate, stiff, or constricted fa shion (Criterion A6). These individuals are often considered to be odd or eccentric because of unu sual m anneris ms, an often unkempt manner of dress that does not quite " fit together," and inattention to the usual social conventions (e.g., the person may avoid eye contact, wear clothes that are ink stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers) (Criterion A7). Individuals with Schizotypal Personality Disorder experience interpersonal relatedness as problematic and are uncomfortable relating to other people. Although they may express unhappiness about their lack of relationships, their behavior s uggests a decreased desire for intimate contacts. As a result, they us ually have no or few dose friend s or confidants other than a first-degree relati ve (Criterion A8). They are anxious in social situations, particularly those involv ing unfamiliar people (Criterion A9). They will interact w ith other p eople when they have to, but prefer to keep to themselves because they feel that they are different and just do not " fit in. " Their social anxiety does n ot easily aba te, even w hen they s pend more time in the setting or become more fami liar with the other people, because their anxiety tends to be associated with s uspiciousness regarding others' motivations. For example, w hen attend ing a dinner party, the individual with Schizot)'pal Personality Disorder will nol become more relaxed as time goes on, but rather may become increasingly tense and
SUSpICIOU S.
Schizotypal Personality Disorder should not be diagnosed if the pa ttern of beha\'ioroccurs exclusively during the course of Sch izophrenia, a Mood Disorder W ith Psychotic Features, another PsychotiC Disorder, or a Pervasive Developmental Di sorder (Criterion B).
Prevale nce
Schizotypal Personality Disorder has been reported to occu r in approximately 3% of the general population.
Cou rse
Schizotypal Personality Disorder has a relatively stable course, with only a small p roportion of individuals going on to d evelop Schizophrenia o r another Psychotic Dis order.
Differential Diagnosis
Schi zotypal Personali ty Disorder can be distinguished from Delusional Disord er, Schi zophrenia, and Mood Disorde r Wi th Psych otic Features because these disor ders are all d laracterized by a period of persistent psychotic symptoms (e.g., delu
700
sicns and hallucinations}. To give an additional d iagnosis of Schizotypai Personality Disorder, the Personality Disorder must have been present before the onset of psychotic symptoms and persis t when the psychotic sym ptoms are in remission. When an ind ividual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by Schizotyp al Personality Disorder, Schizotyp al Personality Disorder should be recorded on Axis II followed by "Premorbid " in p arentheses. There may be g reat difficulty differentiating child ren with SchizotypaJ Personality Disorder from the heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation, eccentricity, or pecu liarities of language and whose diagnoses would probably include milder fonns of A utis tic Di sorder, Asperget's Disorder, and Expressive and M ixed Receptive-Expressive Lang uage Disorders_ Communi cation Disorders may be di fferen tiated by the primacy and severity of the d isorder in language accom panied by compensatory efforts by the child to communicate by other means (e.g., gestures) and by the characteristic features of impaired language found in a specialized language assessment. Milder form s of Autistic Disorder and Asperger's Disorder are d ifferen tiated by the even gre,1ter lack of social awareness and emotional reciprocity and stereotyped behaviors and interests. Schizotypal Personality Disord er mus t be d is tinguished from Personality Change Due to a G eneral M edical Condition, in w hich the traits emerge due to the direct effects of a general med ical condition on the cen tral nervous system. It must also be distinguished from symptoms that may d evelop in associ ation with chroni c substance use (e.g., Cocaine-Related Disorder No t Othenvise Specified ). O ther Personality Disorders may be confused w ith Schizotypal Personality Disorder because they h ave certain features in common. It is, therefore, importan t to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality featu res that meet criteria for one or more Personality Disorders in addition to Schizotypal Personality Disorder, all can be diagnosed . Although Paran oid an d Schizoid Person ality Disorders may also be characterized by social detachment and res tricted affect, Schizotypal Personality Disorder can be d istinguis hed from these hvo diagnoses by the presence of cognitive or perceptual dis tor tions and marked eccentricity or oddness. Close relationships are limited in both Schizotypal Personality Disorder and Avoidant Personali ty Di sord er; however, in Avoid an t Personali ty Disorder an active des ire for relationships is cons trained by a fear of rejection, w h ereas in SchizotypaJ Personality Disorder there is a lack of desire for relationships and persisten t d etachment. Individuals w ith Nardss istic Person ality Disorder may also d isp lay su sp iciousness, social withdrawal, or alienation, but in N arcissistic Person ality Disorder these qualities derive primarily from fears of having imperfections or flaws revealed . Individuals with Borderline Personality Disorder may also h ave transient, psydlOtic-like symptoms, bu t these are usu ally more closely related to affective shifts in response to s tress (e.g ., intense anger, anxiety, or disappoin tment) and are usually more dissocia tive (e.g., d erealization or depersonalization). In contrast, individuals with Schizotypal Personality Disorder are more likely to have end uring psychotic-like symptoms that may worsen wlder stress but are less likely to be in variably associa ted with pronounced affective symptoms. Although social isolation may occur in Borderline Personality Disorder, this is usually secondary to repeated in terpersonal failures due to angry outbursts
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and frequent mood shifts, rather than a result of a persistent lack of social contacts and desire for intimacy. Furthermore, individuals w ith Schizotypal Personality Disorder do not usua lly demonstra te the impu lsive or manipulative behaviors of the individual with Borderline Personality Disorder. H oweve r, there is a high rate of cooccurrence behveen the two disorders, so that making such dis tinctions is not always feasib le. Sch izotypal fea tures during adolescence may be reflective of trans ie nt emotional htrmoil, rather than an enduring personality disorder.
(2)
ideas of reference (exduding delusions of reference) odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations) unusual perceptual experiences, induding bodily illusions odd thinking and speech (e.g ., vague, circumst antial, metapho rical. overelaborate, or stereotyped) suspiciousness or paranoid ideation inappropriate or constricted affect behavior or appearance that is odd, eccentric, or peculiar lack of close friends or confidants other than first-degree relatives excessive social anxiety that does not dimi nish with familiarity and tends to be associated with paranoid fears rather tha n negative judgments about self
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder. Note: If criteria are met prior to the onset of Schizophrenia, add gPremorbid, " e.g., "Schizotypal Personality Disorder (Premorbid).
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This pattern has also been referred toas psychopa thy, sociopathy, or dyssociaJ personality disorder. Because decei t and manipul ation arc central features of Antisocial Personality Disord er, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral sources, For this diagnosis to be given, the ind ividu al mus t be at least age 18 years (Criterion B) and must have had a history of some symptoms of Cond uct Disorder before age 15 years (Criterion C). Conduct Disorder involves a repetitive and persis tent pattern of behavior in w hich the basic rights of others or major age-appropriate societal norms o r rules are violated. The specific behaviors cha racteristic of Conduct Disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious viola tion of rules. These are described in more detail on p. 93. The paHern of antisocial behavior continues into adulthood. lndividuals with Antisocial Personality Disorder fa U to conform to social norms with respect to law ful behavior (Criterion AI). They may repea ledly perform acls thai are g rounds fo r arrest (whether they are arrested or not), su ch as destroying property, harassing others, stealing, or pursuing illegal occu pations. Persons with this d isorder disregard the wishes, rights, or feeling s of others. They are frequently deceitful and manipu lative in order to gain personal profit or pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeatedly lie, use an aJias, can others, or malinger. A pallern of impulsivity may be manifested by a fa ilure to plan ahead (Cri terion A3). Decisions are made on the spur of the moment, w ithout foreth ought, and withou t consideration for the consequences to self or others; this may lead to sudden changes of jobs, residences, or relationships. Individuals with Antisocial Personality Disorder tend to be irritable and aggressive and may repealedly get into physical fights or commi t acts of physical assault (including spou se beating or child bea ting) (C riterion A4). Aggressive acts that are required to defend onesel f or someone else are not considered to be evidence for this item. These individuals also d isplay a reckless disregard for the safety of themselves or others (Criterion AS). ntis may be evidenced in their driving behavior (recurrent speeding, driving w hile intoxicated, multiple accidents). They rna} engage in sexual behav ior or substance use that has a h igh risk for hannful consequences. They may neglect o r fail to care for a child in a way that puts the child in d anger. Individuals wi th Antisodal Personali ty Disorder also lend to be consistently and ex tremely irresponsible (Criterion A6). Irresp onsible work behavior may be indicated by Significant periods of unemployment des pite available job opportunities, or by abandonment of several jobs without a realistic plan for getting another job. There may also bea pattern of repeated absences from work that are not explained by illness either in themselves or in their famil y. Financial irresponsibility is indicated by acts such as defaulting on debts, failin g to prmride child support, or failing to support other dependents on a regular basis. Indiv iduaJs with Antisocial Personality Disorder show little remorse for the consequences of their aels (Criterion A7). They may be ind ifferent to, o r provide a su perficial rational.ization for, having hurt, mistreated, or stolen from someone (e.g., "life's unfair," "losers deserve to lose," or "he had it com ing anyway"). These ind i\riduals may blame the victims for being foolish, helpless, or d eserving their fate; they may minimize the harmful consequences of their actions; or they may simply indicate complete indifference. They generally fail to compensate
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or make amends for their behavior. They may believe that everyone is ou t to "help number one" and that one should stop at nothing to avoid being pushed around. The antisocial behavior must not occur exclusively during the course o f Schizo-phrenia or a Manic Episode (Criterion D).
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misa pplied to individua ls in settings in which seemingly antisocial behavior may be part of a protective survival strategy. In assessing antisocial traits, it is helpful for the
clinician to consider the social and economic context in which the behaviors occur. By definition, Antisocial Personality cannot be diagnosed before age 18 years. Antisocial Personality Disorder is much more common in males than in fema les. There has been some concern that Antisocia l Personality Disorder may be u nderd iagnosed in fe males, particularly because of the emphasis on aggressive items in the definition of Cond uct Disord er.
Preva lence
The overa ll prevalence of Antisocial Persona lity Disorder in community samples is
about 3% in males and about 1% in females. Prevalence es timates within clin ical settings have varied fro m 3% to 30%, depending on the predominant characteristics of the pop ulations being sampled . Even higher prevalence ra tes are associa ted w ith s ubstance abuse trea tment settings and prison or forensic settings.
Co u rse
An tisocial Personality Disorder has a chronic course bu t may become less evident or remit as the indi\'idual grows older, particuJarly by the fourth decade of life. Although this remission tends to be particularly evident w ith respect to engaging in criminal behavior, there is likely to be a decrease in the fu ll spectrum o f an tisocial behav iors and s ubstan ce u se.
Famili al Pattern
Antisocial Persona li ty Disorder is mo re common among the fi rst-degree b iological rela tives of those w ith the d isorder than among the general pop uJation . The risk to biological relatives of fem ales w ith the disorder tend s to be h igher than the risk to biological rela tives of males with the d isord er. Biological rela tives of persons with this d isorder are a lso at increased risk for Somatization Disorder and Subs tance-Related Disorders. Within a fami ly that has a member with Antisocial Personality Disorder, males more often have Antisocial Personality Di sorder an d Subs tance-Related Disorders, w hereas females m ore o ften have Somatization Disord er. However, in such families, there is an increase in p revalence of all of these d isorders in both males and fem ales compared with the general p opulation . Adoption s tudies indicate that both genetic and env ironmental factors con lTibute to the ris k of this group of disorders. Both ad opted and biological children of parents with Antisocial Personality Disorder have an increased risk of d eveloping Antisocial Personality Disorder, Somatization Disorder, and Subs tance-Related Disorders. Ad opted-away children resemble their biological p arents more than their adoptive parents, but the adop tive fam ily en vironment influ ences the ris k of d evelop ing a Personality Disorder and related psychop athology.
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Differential Diagnosis
The d iagnosis of Antisocial Personali ty Disord er is not given to individ uals under age 18 years and is given only if there is a his tory of some symptoms of Conduct Disorder befo re age 15 years. For individ uals over age 18 years, a d iagnosis o f Conduct Disorder is given only if the criteria fo r Antisocial Personality Disorder are not met. When antisocial behavior in an adult is associated with a Substance-Related Disorde r, the diagnosis of Antisocial Personality Disorder is not made unless the signs of Antisocial Personality Disorder were also p resent in childhood and have continued into adulthood. 'When substance use and antisocial behavior both began in childhood and contin ued into adulthood, both a Substance-Related Disorder and Antisocial Personality Disord er should be d iagnosed if the criteria fo r both are met, even though some antisocial acts may be a consequence of the Substance-Rela ted Disorder (e.g., illegal selling of d rugs or thefts to ob tain money fo r d rugs). Antisocial behavior that occurs exclusively during the course of Schizophrenia or a Man ic Episode shou ld not be diagnosed as Antisocial Personality Disorder. Other Personality Disorders may be confu sed with An tisocial Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on d ifferences in their characteristic features. However, if an individ ual has personality fea tu res that meet criteria for one o r more Personality Disorders in addition to Antisocial Personality Disorder, all can be diagnosed. Individuals w ith Antisocial Personality Disorder and Narcissistic Personality Disord er share a tendency to be tough-minded, glib, superficial, exploitative, and unempathic. However, Narcissistic Personality Disorder d oes not includ e characteristics of impulsivity, aggression, and deceit. In addition, individuals with Antisocial Personality Disorder may no t be as needy of the admiration and envy of oU lers, and persons w ith t arcissistic Personality Disorder usually lack the history of Conduct Disorder in child hood or crim inal behavior in ad ulthood. Individuals w ith Antisocial Personality Diso rder and Histri oni c Personality Disord er share a tendency to be impulsive, superfi cia l, excitement seeking, reckless, seductive, and manipulati ve, but persons with Histrionic Personali ty Disorder tend to be more exaggerated in their emotions and d o not characteris tically engage in antisocial behaviors. Individuals with Histrionic and Borderline Personality Disord ers are manipulative to gain nu rnuance, whereas those with Antisocial Personality Disord er are manipu lative to gain profit, power, or some o ther material gratification. Individuals w ith Antisocial Personality Disorder tend to be less emotionally W\StabJe and more aggressive than those with Borderline Personality Disorder. Although antisocial behavior may be present in some individuals w ith Paranoid Personality Disorder, it is not usually motivated by a d esire for personal gain or to exploit others as in Antisocia l Personality Disorder, but ra ther is more o ften due to a desire for revenge. Antisocial Personality Disorder must be d istinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this d isorder. Adult Antisocial Behavior (listed in the "Other Condi tions That May Be a Focus of Clinical Attention" section, p. 740) can be used to describe crimina l, aggressive, or other antisocial behavior that comes to clinical a ttenhon but that does no t meet the full criteria for Antisocial Personality Disorder. Only when antisocial personality traits are inflexible, maladaptive, and persisten t and cause significant fu nc-
706
by repeatedly performing acts that are grounds for arrest (2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others
for personal profit or pleasure (3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness. as indicated by repeated physical fights or assaults (5) reckless disregard for safety of self or others (6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financia l obligations (7) lack of remorse, as indicated by being indifferent to or rationaliZing having hurt, mistreated, or stolen from another B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder (see p. 98) with onset before age 15 years.
D. The occurrence of antisocial be havior is not exclusively during the course of Schizophrenia or a Manic Episode.
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Di agnosti c Features
The essential feature of Borderline Personality Disorder is a perv asive pattern of in stability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts. Individuals with Borderline Personality Disorder make fran tic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonmen t fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician's announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them . Their fr.lntic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.
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Ind iv iduals w ith Bo rderline Personality Disorder h ave a pattern of unstable and intense relationships (Criterion 2). They may idealize potentia l caregivers or lovers at the fi rst or second meeting, demand to s pend a lot of time together, and sh are the most in tima te details early in a relationship. However, they may switch quickly from idealizing other p eop le to devaluing them, feeling that the other p erson d oes not care enough, does n ot give enou gh, is not " there" enough. These individ u als can empathize with and nurture other p eople, but only w ith the expectation that the o ther person w ill "be there" in return to m eet their own needs on d emand. These individuals il rc prone to sudden and dramatic shifts in their view of o thers, who may alternately be seen as beneficent su pports or as cruelly punitive. Such shifts often reflect disillu sionment w ith a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected. There may be an id enti ty d isturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and d ramatic shi fts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, ,'alues, and types of friends. These individuals may sudden ly change from the role of a needy supplicant fo r help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, ind ividuals w ith this disorder may at times have feelings that they d o not exist at all . Such experiences usually occu r in situations in which the ind ividual feel s a lack of a meaningful relationship, n urturing, and support. These indi viduals may show worse performance in unstructured work or school situations. Ind iv id uals with this d isorder d isplay imp ulsivity in at least h vo areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or d rive recklessly. Ind ividuals with Borderline Personality Oisorder display recurrent suicidal behavio r, gestu res, or threats, or self-mutila ting beha vior (Criterion 5). Completed suicide occurs in 80/010% of such individuals, and self-muti lative acts (e.g., cutting or burning) and suicid e threats and attempts are very common . Recurrent suicidality is often the reason that these individuals present for help. These self-d estructive acts are usuaUy precipitated by threats of separation o r rejection or by expectations that they assu me increased responsibility. Self-mutilation may occur d uring dissocia tive experiences and oft en brings relief by reaffirmin g the ability to feel or by expiating the individual's sense of being evil. Ind iv id uals with Borderline Personality Disorder may d isp lay affective instability Ihat is due to a m arked reactivity of mood (e.g., in tense episodic dysphoria, irritability. or anxiety usually lasting a few hours and only rarely more than a fe w d ays) (Criterion 6). The basic d ysphoriC mood of those w ith Borderline Personality Oisorder is often disrupted by periods of anger, panic, o r d espair and is rarely relieved by periods of well-being or sa tis faction. These episod es may refl ect the individual 's extreme reacti vity to interpersonal stresses. Indi viduals with Borderline Personality Disorder may be troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to d o. Individuals w ith Borderline Personality Disorder frequently express inappropriate, in tense anger o r have difficulty contro lling their anger (Criterion 8). They may dis play extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as
neglectful, withhold ing, uncaring, or abandoning. Such expressions o f anger are of ten followed by shame and guilt and con tribute to the feeling they have of being evil. During period s of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonmenl. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver's nurturance may result in a remission of symptoms.
Preva lence
The prevalence of Borderline Personality Disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatriC inpatients. It ranges from 30% to 60% among clinical popula tions w ith Personality Disorders.
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Course
There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use o f health and mental hea lth resources. The impairment from the disorder and the risk of suicide are greatest in the YOUIlg-adult years and g radually wane with advancing age. Allhough the tendency toward intense emoti ons, impulsiv ity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Follow-up studies of individua ls identified throu gh ou tpatient mental health clinics indica te that after about 10 years, as many as half of the individuals no longer have a pattern of behavior that meets full criteria for Borderline Personality Disorder.
Differential Diagnosis
Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria for both are met, both may be diagnosed . Because the cross-sectional presentation of Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the c1inidan shou ld avoid giving an additional diagnosis of Borderline Persona lity Disorder based only on cross-sectional presentation without having documented that the pattern o f behavior has an early onset and a long-standing course. Other Personality Disorders may be confused with Borderline Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic feature s. However, if an individual has personality features that meet criteria for one o r more Personality Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Although Histri onic Person ality Disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, Borderline Personality Disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both Borderline Personality Disorder and Sch izotypal Personality Disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in Borderline Personality Di sorder. Although Paranoid Personality Disorder and Narci ssistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from Borderline Personality Dis-
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Personality Disorders
order. Although Antisocial Personality Disorder and Borderline Personality Disorder are both characterized by manipulative behavior, individuals with Antisocial Personality Disorder are manipulative to gain profit, p ower, or some other material g ratification, whereas the goal in Borderline Personality Disorder is directed more toward gaining the concern of ca retakers. Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment; however, the individual with Borderline Personality Disorder reacts to abandonment wi th feel-
ings of emotional emptiness. rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relations hip to prov ide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personali ty Disorder by the typical pattern of unstable and intense relationships. Bord erline Personality Disorder must be distinguished from Personality Change Du e to a General Medical Cond ition, in which the traits emerge due to the direct effeets of a general medical condition on the central nervou s system. It must also be distinguished from sym p toms th ai may develop in association with chronic s ubstance use (e.g., Cocaine-Related Disorder at Othen\'ise Specified). Borderline Personality Disorder should be distinguis hed from Identity Problem (see p. 741), which is resen'ed (or identity concerns related to a d evelopmental phase (e.g., adolescence) and d oes not q ualify as a mental disorder.
(S) (6)
cidal or self-mut ilating behavior covered in Criterion S. a pattern of unstable and intense interpersonal relationships characterized by alter nating between extremes of idealization and devaluation identity disturbance: markedly and persistently unstable se lf-image or sense of self impulsivity in at least two areas that are potentia lly self-damag ing (e.g., spending, sex, substance abuse. reckless driving. binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion S. recurrent suicidal behavior. gestures. or threats. or self-mutilating behavior affective instability due to a marked reactivity of mood (e.g .. intense episodic dys' phoria. irritability. or anxiety usually lasting a few hours and only rarely more than a few days) chronic fee lings of emptiness inappropriate, intense anger or difficu lty controlling anger (e.g . frequent displays of temper. consta nt anger. recurrent physical fights) transient. stressrelated paranoid ideation or severe dissociative symptoms
301.50
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301.50
Diagnostic Features
The essentiaJ feature of Histrionic Personality Disorder is pen'asive and excessive emotionality and attentionseeking behavior. nlis pattern begins by early adulthood and is present in a variety of contexts. Individuals with His trionic Personality Disorder are uncomfortable or fee l unapprecia ted w hen they arc not the ccnter of attention (Criterion 1). Often livel}' and dramatic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, .1pparent openness, or flirtatious ness. These qualities wear thin, however, as these individ uals continually demand to be the center of attention. They commandeer the role of " the life of the party." If they are not the cen ter of attention, the)' may do something dramatic (e.g., make up s tories, create a scene) to draw the focus of attention to themselves. TIlis need is often apparent in their behavior with a clinician (e.g., fl attery, bringing g ifts, prov iding dramatic de scriptions of physical and psychological symptoms that are replaced by new symptoms each visit). The appearance and behavior of individuals with this di sorder a re often inappropriately sexually provocative or seductive (Criterion 2). This behavior is directed not only toward persons in whom the individual has a sexual or rom.mtic interest, but oc curs in a wide variety of social, occupational, and professional relationships beyond what is appropriate for the social context. Emotional expression may be shallow and rapidly s hifting (Criterion 3). In dividuals with this d isorder consis tently use physical appearance to dr.l \\, attention to themselves (Criterion 4). They are overly concerned with impressing others by their appearance and exp end an excessive amount of time, energy, and money on clothes and grooming. They may "fish for compliments" regarding appearance and be easily and excessively upset by a critical comment about how they look or by a photograph that they regard as unflattering. These individuals have a s tyle of speech that is excessively impressionistic and lacking in detail (Criterion 5). Strong opinions a re expressed with d ranl.ltic flair, but underlying reasons are usually vague and diffuse, without supporting fa cts and details. For example, an indi vidual with Histrionic Personality Disorder may comment that a certain ind iv iduaJ is a wonderful human being, yet be wlable to provide any specific examples of good qualities to support this opinion. Individuals with this disorder are characterized by self-dramatization, theatricali ty, and an exaggerated expression of emotion (Criterion 6). They may embarrass fri ends and acquaintances by an excessive public display of emotions (e.g., embraCing casual acquaintances with excessive ardor, sobbing uncontroUably on minor sentimental occasions, or having temper tantrums). However, their emotions often seem to be turned on and off too quickly to be d eeply felt, which may lead others to accuse the individual of faking these feelings. Individuals with His trionic Personality Disorder have a high degree of s uggestibility (Criterion 7). Their opinions and feelings arc easily influenced by others and by current fads. They may be overly trusting, especially of strong authority figures whom they see as magically solving their problems. They have a tendency to play
712
Personality Disorders
hunches and to adopt convictions quickly . Individuals with this disorder often consider relationships more intima te than they actually are, describing almost every acquaintance as "my d ear, dear friend " or referring to physicia ns met only once or h vice under pro fessional circums tances by their first names (Cri terion 8). Flight s into romantic fanta sy are common.
301.50
713 1
Prevalence
Limited data from general population s tudies s uggest a prevalence of His trionic Personality Disorder of abo ut 20/ -3%. Rates of about 10%- 15% have been rep orted in in0 patient and outpatient mental health settings ,,'hen structured assessment is u sed.
1 714
Personality Disorders
lowing:
(1) is uncomfortable in situations in which he or she is not the (enter of attention (2) interaction with others is often characterized by inappropriat e sexually seductive or provocative behavior (3) displays rapidly shifting and shallow expression of emotions
consist ently uses physical appearance to draw attention to self has a style of speech that is excessively impressionist ic a nd Jacking in detail shows self.d ramatization, theatricality. and exaggerated expression of emotion is suggertible, i.e., easily influenced by others or circumstances considers relationships to be more intimate than they actua lly are
301.81
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715
how well they are d oing and how favorably they are regarded by others. This often takes the form of a need for constan t attention and admiration. They may expect their arrival to be greeted w ith g reat fanfare and are astonished if others do not covet their possessions. TIleY may constantly fis h for complimen ts, often with great charm . A sense of en titlement is evident in these ind ividuals' unreasonable exp ectation of especially favorable treatment (Criterion 5). They expect to be catered to and are puzzled or furious w hen this does not happen. For example, they may assume that they do not have to wait in line and that their priorities are so important that others s hould defer to them, and then get irritated when others fai l to assis t "in their very important work. " This sense of entitlemen t comb ined with a lack of sensitivity to the wants and needs of others may result in the conscious or unw itting exploitation of others (Cri terion 6). They expect to be g iven whatever they want or fee l they need, no matter w hat it might mean to others. For example, these individuals may expect great d ed ication from others and may overwork them w ithout regard for the impact on their lives. They tend to fonn friend ships or romantic relationships only if the other person seems likely to advance their purposes or o therw ise enhance their self-es teem. TIley often us urp s pecial privileges and extra resources that they believe they d eserve because they are so special . Ind ividuals with arcissistic Personality Disorder generally have a lack of empathy and have difficulty recognizing the desires, subjective experiences, and feelings of others (Criterion 7). They may assume thai others are totally concerned about their welfare. They tend to d iscuss their own concerns in inappropria te and lengthy detail, while failing to recognize that others also have feelings and need s. They are often contemptllo us and impatient with others who talk about their own problems and concerns. TIlcse individllals rna)' be oblivious to the hurt their remarks may innict (e.g ., exuberantly telling a fonner lover tha t " I am now in the relationship of a lifetime!"; boasting of heal th in front of someone who is sick). When recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness or vu lnerability. Those w ho relate to individuals w ith arcissis tic Personality Disorder typically find an emotional coldness and lack o f recip rocal interest. These indi viduals are often envious o f others or b elieve that others are en vious of them (C riterion 8). They may begrudge o thers their successes or possessions, feeling that they better deserve those achievements, admiration, or privileges. They rna}' harshly dcvahle the contributions of others, particularl y w hen those individuals have received acknow ledgment or praise for their accomplishments. Arrogant, haughty beha\'iors characterize these individuals. They often display snobbish, disda inful, or patronizing attitudes (Criterion 9). For example, an indi vidual with th is disorder may complain about a clumsy waiter's "rudeness" or "stupidity" or conclude a medical evaluation with a cond escend ing evaluation of the physician.
716
humility that may mask and protect the grandiosity. interpersonal relations arc typica lly impaired due to problems d erived from en ti tlement, the need for admiration, and the relative disregard for the sensitivities of others. Though overweening ambition and con fide nce may lead to high achievement, performance m ay be d is rupted due to intolerance of criticism or defea t. Sometimes vocational functioning can be \'ery low, rcnecting an unwillingness to take a risk in competitive or other situations in which defea t is possible. Susta ined feelings of sham e or humiliation and the attendanl self-criticism may be associated w ith social w ithdrawal, depressed mood, and Dysthymic or Major Depressive Disorder. In contrast, sustained periods of grandiosity may be associa ted with a hypomanic mood . Narcissistic Personality Disorder is ervosa and Substance-Rela ted Disorders (especially also associa ted w ith Anorexia T related to coca ine). Histrionic, Borderline, Antisocial, and Paranoid Personality Disorders may be associa ted with Narcissistic Personality Disorder.
Prevalence
Estimates o f prevalence of Narcissistic Personality Disorder range from 2% to 16% in the clinical population and are less than 1% in the general population.
Differential Diagnosis
Other Personality Disorders may be confused with Narcissistic Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these d isorders based on differences in their characteris tic features . However, if an individual ha s personality features that meet criteria for one or more Personality Disorders in add ition to I arcissistic Personality Disorder, aU can be diagnosed . The most u seful feature in discriminating Niu cissistic Personality Disorder from Histrion ic, Antisocial, and Borderline Personality Disorders, whose interactive styles arc respectively coquettish , callous, and needy, is the grandiosity characteristic of I arcissistic Personality Disorder. The rela tive stability of self-image as well as the relative lack of self-destructiveness, impulsiv ity, and aba ndonment concerns also help d istinguish Narcissistic Personality Disorder from Borderline Personality Disorder. Excessive pride in adlievements, a relative lack of emotional disp lay, and disdain for others' sensitiv ities help distinguish Narcissistic Person ality Disorder from Hislrionic Personality Disorder. Although individuals w ith Borderline, H istrionic, and 'arcissistic Personality Disorders may require much atten tion, those with 'arcissistic Personality Disorder specifically need thai attention to be admiring. individuals with Antisocial and Narcissistic Personality Disorders will share a tendency to be tough-minded , g lib, s uperficial, exploita tive, and unem patllic. However,
301.8 1
717 1
Narcissistic Personality Disorder does not necessarily include characteristics of impulsivity, aggression, an d deceit. In addition, individuals with An tisocial Personality Disorder may not be as needy of the admiration and en vy of others, and persons with Narcissistic Personality Disord er usuaUy lack the history of Conduct Diso rd er in child hood or criminal behavior in adu lthood. In bo th Narcissistic Persona lity Disorder and Obsessive-Comp ulsive Personality Disorder, the indiv idual may p rofess a commitmen t to perfectionism and believe that o thers cannot do things as well. In contrast to the accompanying seU-criticism of those w ith Obsessive-Compulsive Personality Disorder, individ uals with Narcissis tic Personality Disorder are more likely to believe tha t they have achieved perfection. Suspiciousness and social w ithdrawa l usually distinguish those with Sch izotypal or Paranoid Persona li ty Disorder from those wi th Narcissistic Personality Disorder. When these quali ties are present in individuals with Narcissistic Personality Disorder, they d erive primaril y from fears of having imp erfections or fl aws revea led. Grandiosity may emerge as part of M anic or Hypo mani c Episodes, bu t the association w ith mood change o r fun ctional impairments helps di stinguish these episod es from Narcissis tic Personalit}' Disorder. Narcissistic Personality Disorder must also be distinguished from sy m ptoms th at m ay develop in associa tion wi th ch ronic s ub s tance use (e.g., Cocaine-Related Disorder Not Othenvise Speci fi ed). Many highly successfu l individuals display personality t raits tha t might be considered narcissis tic. O nly when these traits are infl exible, maladaptive, and persisting and ca use significant fWlCtionai impairment or s ubjective distress do they constitute Narcissis tic Personality Disorder.
ents, expects to be recognized as superior without commensurate achievements) is preoccupied with fant asies of unlimited success, power, brill iance, beauty, or ideal Jove believes that he or she is "special" and unique and can only be understood by, or should associate wit h, other special or high-status people (or institutions) requires excessive admiration has a sense of entitlement, i.e., unreasonable expectations of especia lly favo ra ble treat ment or automa tic compliance with his or her expectations is interpersona lly exploitative, i.e., takes advantage of others to achieve his or her own ends lacks empathy: is unwilling to recognize or identify with t he fee li ngs and needs of others is often envious of others or believes t hat ot hers are envious of hi m or her shows arroga nt, haughty be haviors or attitudes
718
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Preva lence
The p revalence of Avoidant Personality Disorder in the general population is between 0.5% and 1.0%. Avoidant Personality Disorder has been reported to be present in about 10% of outpatients seen in mental health clinics.
Course
The avoid ant behavior often s tarts in infancy or childhood w ith s hyness, isolation, and fea r of strangers and new situations. Although shyn ess in childhood is a conmlOn precursor o f Avoidant Personality Disorder. in most individuals it tends to g radually dissipate as they get older. In contrast, ind ividuals who go on to develop Avoidant Personality Disorder may become increasingly shy and avoidant during adolescence
720
and early adulthood, when social rela tionships with new people become especially important. 111ere is some evidence thai in adults Avoidan t Personality Disorder tends
to become less evident or to remi t with age.
the onset of Panic Attacks and may vary based on their frequency and intensity. In contrast, the avoid ance in Avoidant Personality Disorde r tend s to have an early onset, an absence of clear precipi tants, and a stable course. Other Personality Disorders may be confused w ith Avoidant Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these d isord ers based on d ifferences in their characteristic features. However, if an individua l has personality featu res tha t meet criteria for one o r more Personality Disorders in addition to Avoidant Personality Disorder, all can be diagnosed . Both Avoidant Personality Diso rder and Dependent Personality Di sorder are characterized by feelings of inad equacy, hypersensitivity to criticism, and a need for reassu rance. Although the prim ary focus of concern in A\'oidant Personality Disorder is avoid ance o f humilia tion and rejection, in Depend en t Personality Disorder the focus is on being taken care of. H owever, Avoidant Personality Disorder and Dependent Personality Disorder are particularly likely to co-occur. Like Avoidant Personality Disorder, Schizoid Personality Disorder and Schizotypal Personality Disorder are characterized by socia l isola tion. However, ind ivid uals w ith Avoidant Personality Disord er want to have relationships with others and feel their loneliness deeply, whereas those w ith Schizoid or Schizotypal Personality Disorder may be content w ith and even p refer their social isolation . Paranoid Personality Di sorder and Avoid ant Personal ity Disorder are both characterized by a reluctance to confid e in others. However, in Avoid ant Personality Disorder, this reluctance is du e more to a fear of being embarrassed or being found inadequate than to a fea r o f others' ma liciou s intent. Avoidant Personality Disorder m ust be distinguished from Personality Change Due to a Ge neral Medical Conditi on, in w hich the traits emerge due to the d irect effects o f a general medical condition on the central nervous system. It must also be distinguished h om symptoms that m ay d evelop in association with chroni c substan ce use (e.g., Cocaine-Rela ted Disord er Not Otherwise Specified ). Many individuals d isplay avo id ant personali ty traits. OnI)' when these traits are inflexible, malad ap tive, and persisting and cause significant fun ctional impairment or subjective distress do they constitute Avoidant Personality Disord er.
721
of fears of criticism, disapproval, or rejection is unw ill ing to get involved with people unless certain of being l iked shows restraint w ithin i nt imate relationships because of the fear of being shamed or ridiculed is preoccupi ed with being criticized or rejected in social situations is inhibited in new interpersonal situations because of feelings of inadequacy views self as socially inept, personal ly unappea ling, or inferi or to others is unusually relucta nt to take persona l risks or to engage in any new activit ies because they may prove embarrassing
301.6
Diagnostic Features
The essen tial feature of Dependent Personality Disorder is a pervasive and excessive nCd to be taken care of that leads to submissive and clinging behavior and fears of separation_This pattern begins by early adulthood and is present in a variety of contex ts_ The dependent and submissive behav iors are designed to elicit caregiving and arise from a seUperception of being unable to functi on adequa tely without the help of others. Individuals w ith Dependent Pe rsonality Disorder have great difficulty making everyday decision s (c_g., w hat color sh irt to wear to work or whether to carry an urn brella) without an excessive amount of advice and reassurance from others (Criterion 1). These individuals tend to be passive and to allow other people (often a single olher person) 10 take the initia tive and assume responsibility for most major areas of their lives (Criterion 2). Adults with this d isorder typically depend on a parent or sp ouse 10 d ecide where they should live, wh at kind of job Ihey shou ld h ave, and which neighbors to befriend. Adolescents w ith this disorder may allow their p arenl(s) to de cide what they should wea r, with whom they should associate, how they should spend their free tinle, and whal school or college they should attend. This need for others to assume responsibility goes beyond age--appropriate and situationappropriate re quests for assistance from others (e_g_, the specific needs o f children, elderly persons, and handicapped persons). Dependen t Personality Disorder may occur in an ind ividual w ho has a serious general medical condition or disability, but in such cases Ihe difficulty in taking responsibili ty mus t go beyond what would normally be associat cd with that condition or d isability.
722
Beca use they fear losing support or approval, individ uals w ith De pendent Personality Disorder often have d ifficulty expressing d isagreement w ith o ther people, espe.-
cially those on whom they are dependent (Criterion 3). These individuals feel so lmable to fu nction alone thai they w ill agree with thing s tha t they feel arc wrong rath er than risk losing the help of those to whom they look for guidance. They do not gel appropriately angry at others whose support and nurturance they need for fear of alienating them. If the individual's concerns regard ing the consequences o f expressing d isagreement are realistic (e.g., real istic fears o f retribu tion fro m an abusive
sp ouse), the behavior s ho uld not be considered to be eviden ce of Dependen t Personali ty Disord er. Individ u als with this disorder have difficul ty initiating p rojects or d oing things independently (Criterion 4). They lack self-confidence and believe that they n eed help to begin and carry through tas ks. They w ill wait fo r others to s tart things beca use they believe that as a rule others can d o them better. These individ uals are con vinced thai they are incapa ble of functioning independen tl y and present them selves as inept and requi ring constant assis tance. They are, however, likely to fu nction adequately if given the assurance that someone else is su pervising and app ro ving . There m ay be a fear of becoming o r a p pearin g to be more com petent, beca use they may believe that this will lead to abandonment. Beca us e they rely on others to h andle their prob lems, they often do not learn the s kills o f indep endent living, thus p erpetuating d epend ency. Individuals with Dependent Personality Disorder may go to excessive lengths to obtain nurturance and s upport from others, even to the point of vol unteering for un p leasant tas ks if s uch behav ior will bring the ca re they need (Criterion 5). They are willing to submit to what others want, even if the d emands are unreasonable. Their need to maintain a n important bond w iII often result in imba lanced o r dis torted relationships. They may make extraord inary seU-sacrifices or tolerate verba l, ph ysical, or sexual abuse. (It sh ould be noted that this behavior should be cons idered ev id ence of Dependent Personality Diso rder onJy w h en it can clearly be esta blis hed that other options a re available to the individual.) Individuals with this d is order feel uncomfortable or helpless w hen alone, becaus e of thei r exaggera ted fears of being una ble to care for themselves (Criterion 6). They will "tag along" w ith im por ta nt o thers jus t to avoid being alone, even if they arc not interes ted or involved in what is ha ppening. Wh en a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), ind ividuals with Dependent Personali ty Disorder may urgently seek another relationship to provide the care and support they need (Criterion 7). Their belief that they are unable to fu nction in the absence of a close rela tionship motiva tes these ind ividuals to become qu ickly and indiscrimina tely attaclled to another p erson . Individuals with this d isorder are often p reoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so tota lly de pend ent on the advice an d help of an impor tant other p erson th a t they worry about being aband oned by that person w hen there are no grounds to justify such fears. To be considered as evi dence of tltis criterion, the fea rs mus t be excessive and tmrealis tic. For example, an elderly man with cancer who moves into h is son 's household for care is exhibiting dependent behavior that is app ropriate given Utis person 's life ci rcumstances.
301 .6
723
Prevalence
Dependent Personality Disorder is among the most frequently reported Personality Disord ers encountered in mental health clinics.
Differential Diagnosis
Dependent Personality Disorder must be dis tinguished from d ep endency arising as a consequence of Axis I disorders (e.g ., Mood Disorders, Panic Disorder, and Agoraphobia) and as a result of general medical conditions. Dependent Personali ty Disorder has an early onset, chronic course, and a pattern of behav ior that does not occur exclusively during an Axis I or Axis 111 disorder. Other Personality Disorders may be confused with Dependent Personality Disorder because they ha ve certain features in common. It is, therefore, important to distinguish among these d isorders based on differences in their characteris tic features. However, if an i.ndividual has personality features tha t m eet criteria for one or more
1724
Personality Disorders
Personality Disorders in addition to Dependen t Personality Disorder, aU can be diag nosed. Although many Personality Disorders are characterized by dependent features, Dependent Personali ty Disorder can be dis tinguished by its predominantly submissive, reactive, and clinging behavior. Both Depend ent Personality Disorder and Borderline Personality Disorder are ch aracterized by fear of abandonment; however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness. rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacemen t relations hip 10 provide caregiving and support. Borderline Personality Disorder can further be d is tingu ished h om Dependent Personality Disorder by a typical pattern of unstable and intense relationships. Individuals with Histrionic Personality Disorder, like those w ith Dependent Personal ity Disorder, have a s trong need for reassurance and approval and may appear ch ildlike and clinging. However, u nlike Dependent Persona lity Disorder, which is characterized by self-effacing and docile behavior, Histrionic Persona lity Disorder is characterized by gregarious namboya nce with active d emands for attention. Both Dependent Personali ty Disorder and Avoidant Personality Diso rder are characterized by feelings of inadequacy, hypersensitivity to cri ticis m, and a need for reassurance; however, individuals with Avoidant Personality Disorder have such a stron g fear of humilia tion and rejection that they withdraw unti l they are certain they w ill be accepted. In contrast, individuals wi th Dependent Personality Disorder have a pattern of seeking and maintaining connections to important others, rather than avoiding and withdraw ing from relations hips. Dependen t Personality Disorder mus t be dis tinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effec ts of a general medical condition on the central nervous system . It must also be distinguished fro m symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder 'at Othem'ise Specified). Many individuals display dependent personality traits. O nly when these tra ils are inflexible, maladaptive, and persis ting and cause significant functional impairment o r subjective distress do they constitu te Dependent Personality Disorder.
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726
tion," Deadlines are missed, and aspects of the individual's life that are not the current focus of activity may fall into disarray. Individuals w ith Obsessive-Compulsive Personality Disorder display excessive devotion to work and productivity to the exclusion o f leisure activities and friendships (Criterion 3). nus behavior is no t accounted for by economic necessity. They of-
ten feel that they do not have time to take an evening or a weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. \,\' hen they do take time for leisure acti vities or " acations, they are very uncomfortable unless Ihey have taken along something to
work on so they do n ot " was le time." There may be a grea t concentra tion o n household chores (e.g., re peated excessive cleaning so tha t "one could cat off the floor"). If they spend time w ith frie nds, it is likely to be in some kind of formall y o rganized activity (e.g., sports). H obbies or recreational activities a re approadled as serious tasks requiring careful o rganization and hard work to mas ter. The emph asis is on perfect performance. These individuals tum play into a structured tas k (e.g., correcting an i.nfant fo r not putting rings o n the post in the right order; telling a toddler to r ide his or her tricycle in a s tra ight line; turning a baseball game into a harsh "lesson"). Individuals w ith Obsessive-Compulsive Pe rsonality Disorder may be excessively conscientiou s, scrupulou s, a nd inflex ible about matters of m o rality, e thics, or values (C ri terion 4). They may force themselves and others to follow rigid m oral principles and very strict standards of performance. They may also be mercilessly sel f-critical about their own mistakes. Individ uals with this disorder are rigidly deferential to a utho rity and rules and ins is t o n quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will no t lend a quarter to a friend w ho needs o ne to make a telephone call, because " neither a borrower or lender be" o r because it would be "bad" for the person 's cha racte r. These qualities should not be accmmted for by the individual 's cultural or religious identification. Individuals w ith this disorder may be unable to discard worn-out or worthless objects, even w hen they have no sentimental value (Criterion 5). Often these individuals w ill admit to being " pack ra ts." They regard discarding objects as was teful because "you never know when you m ight need something" and w ill become upset if someone tries to get rid of the things they have saved. Their spouses or roomma tes m ay complain about the a mount of space taken up by old parts, magazines, broken appliances, and so on. Individuals w ith Obsessive-Compulsive Pe rsonality Disorder are reluctant to de lega te tasks or to wor k with others (Criterion 6). They stubbornly and unreasonably insist that e verything be do ne their way and that people conform to their way of doing things. They often give very detailed instructions abo ut how things should be done (e.g., there is one and only one way to m ow the lawn , wash the dis hes, build a doghouse) and a re surprised and irritated if others su ggest creative alternatives. At other times they may reject offers of help even when behind schedule becau se they believe no one e lse can do it r ight. Individuals w ith this disord e r may be m iserly and s tingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to prov ide for future catastrophes (Criterion 7). Indi viduals with ObsessiveCompulsive Pe rsonality Disorder are characterized by rigidity and s tubbornness (Criterio n 8). They a re so concerned about having things done the one "correct" way
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that they have trouble going along with anyone else's ideas. These individuals plan ahead in meticulous detail and are unwilling to consider changes. Totally wrapped up in their own perspective, they have d ifficulty acknowledging the viewpoints of others. Friends and colleagues may become frustrated by this constant rigidity. Even when individuals with Obsessive-Compulsive Personali ty Disorder recognize that it may be in their interest to compromise, they may s tubbornly rehlse to do so, arguing that it is "the principle of the thing."
728
Specific Culture and Gender Featu res
In assessing an indi\,jdual for Obsessive-Compuls ive Personality Disorder, the clinician should not include those behav iors that reflect habits, customs, or interpersonal styles that aTC culturally sanctioned by the individual's reference group. Certain cultures place subs tantial emphasis on work and productivity; the resulting behaviors in members of those societies need not be considered indications of ObsessiveCompulsive Personali ty Disorder. In systematic s tudi es, the disorder appears to be diagnosed aboullwice as often among males.
Prevalence
Studies that have used systematic assessment suggest prevalence estimates of Obsessive-Compulsive Personali ty Disorder of about 1% in commtmity samples and about 3%-10% in individuals presenting to mental health clinics.
Differential Diagnosis
Despite the similarity in names, Obsessive-Compuls ive Disorder is us ually easily distinguished from Obsessive-Compulsive Personali ty Di sorder by the presence of true obsessions and compulsions. A diagnosis of Obsessive-Compulsive Disorder should be considered especially when hoarding is ex treme (e.g ., accumulated s tacks of worthless objects present a fire hazard and make it d ifficult for others to walk through the house). \O\'hen criteria for both disorders are met, both diagnoses s hould be recorded. Other Personality Disorders may be confused with Obsessive-Compulsive Personality Disorder because they have certain feah.ues in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features . However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Obsessive-Compulsive Personality Disorder, all can be diagnosed . Individuals with Narcissistic Personality Disorder may also profess a com.!n.itment to perfectionism and believe that others cannot do things as well, but these individuals are more likely to believe that they have achieved perfection , whereas those with Obsessive-Compulsive Personality Disorder are usually self-critical. Individuals with Narcissistic or An ti social Personality Disorder lack generosity but will indulge themselves, whereas those with Obsessive-Compulsive Personality Disorder adopt a miserly spending style tow ard both self and others. Both Schizoid Personality Disorder and Obsessive-Compulsive Personality Disord er may be characterized by an apparent formali ty and social detachment. In Obsessive-Compulsive Personali ty Disorder, this s tems from discomfort with emotions and excessive devotion to work, whereas in Schizoid Personality Disorder there is a fundamen tal lack of capacity for intimacy. Obsessive-Compulsive Personality Disorder must be distinguished from Personality Ch ange Due to a General Medical Condition, in which the traits emerge due to the direct effecls of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substan ce use (e.g., Cocaine-Related Disorder Not O therwise Specified).
301.9
729
Obsessive-compulsive personality traits in moderation may be especiall y adaptive, particularly in sihlations that reward high perfomlance . Only w hen these traits are inflexible, maladaptive, and persisting and cause s ignificant func tiona l impairmentor subjective distress do they constitute Obsessive-Compulsive Personality Disorder.
his section covers other conditions or p roblems that may be a focus of clinical atlention. These are related to the mental disorders described previously in this manual in one of the following ways: 1) the problem is the focus o f diagnosis or treatment and the individual has no mental disorder (e.g., a Partner Relational Problem in which neither partner has symptoms that meet criteria for a mental disorder, in which case onl y the Partner Relational Problem is coded); 2) the individual has a mental disorder but it is unrelated to the problem (e.g., a Partner Relational Problem in which one of the partners has an incidental Specific Phobia, in w hich case both can be coded); 3) the individual has a mental disorder that is related to the problem, but the problem is sufficiently severe to warrant ind ependent clinical attention (e.g., a Partner Relational Problem sufficiently problematic to be a focus of treatment that is also associated with 1>.'lajor Depressive Disorder in one of the partners, in w hich case both can be coded). The cond itions and problems in this section are coded on Axis I.
731
732
with coronary artery disease, or bronchospas m in individuals with asthma). The psychological or beha vioral factors that in flu ence general medical conditions include Axis I disorders, Axis IT diso rders, psychologica l symptoms or personality traits that do not meet the full criteria for a s pecific m ental disorder, maladaptive health beha viors, o r physiological responses to environmen tal or socia l s tressors.
316
733
practices, overeating, excessive alcohol and drug use) significantly affect the course or trea tment of a general medical condition. If the maladaptive behaviors are better accounted for by an Axis I d isorder (e.g., overeating as part of Bulimia ervosa, alcohol u se as part of Alcohol Dependence), the name ''Nlen tal Disorder Affecting Medical Condition " should be used instead. Stress-Related Physiological Res pon se Affecting . .. rr"dic(lte tile Gellernl M edic(l f COlld itio"]. Stress-related physiological responses significant ly affect the course or treatment of a general medical condition (e.g., precipitate chest pain or arrhythmia in a patient with coronary artery disease). Other or Uns pecified Factors Aff ec ting . . . [Indicate tI'e Ge"eraf Medi c(l f Co"diti oll ]. A fac tor no t inclu ded in the subtypes specified above or an unspecified psychological or behaviora l factor significan tly affects the course o r treahnent of a general medical cond illon.
Differentia l Diagnosis
A temporal association between symptoms of a men tal disorder and a genera l medical condition is also characteristic of a Mental Disorder Due to a General Med ical Condition, but the p resumed causality is in the opposite d irection. In a Mental Disorder Due to a General Medical Cond ition, the general medical condition is judged to be causing the mental disorder through a direct physiological mechanism . In Psychologica l Factor Affecting Medica l Cond ition, the psychological or beh avioral factors are judged to affect the cou rse of the general medica l condition. Subs tance Use Disorders (e.g., Alcohol Dependence, kotine Dependence) adversely affect the prognosis of many general medical conditions. If an individual has a coexisting Substance Use Disorder that adversely affects or causes a general medical condition, Menta l Disorder Affecting General Medical Condi tion can be coded on Axis I in addition to the Substance Use Disorder. For substance use patterns affecting a general med ical cond ition that do not meet the criteria for a Substance Use Disorder, ~'I aladapti"e Health Behaviors Affecting Med ical Cond ition ca n be specified. Somatoform Disorders are characterized by the p resence of both psychological facto rs and ph ysical symptoms, but there is no general medical condition that can completely account for the physical symptoms. In con trast, in PsydlOlogica l Factors Affecting Med ical Condition, the psychological fac tors adversely affect a diagnosable general medical condition. PsycholOgical factors a ffec ting pain syndromes are not diagnosed as Psychological Factor Affecting Medical Cond ition but rather as Pain Disord er Associated With Psych ological Factors or Pain Disorder Associated With Both Psychological Factors and a Gen eral M edical Con di tion. When noncompliance with treatment for a general medical condition results from psychological fac tors but becomes the major focus o f clinical atten tion, Noncompliance With Treatment (see p. 739) should be coded .
the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition (2) the factors interfere with the treatment of the general medical cond ition (3) the factors constitute add it ional health risks for the individual (4) stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition
Choose name based on the nature of the psycholog ica l factors (if more than one factor is present, indicate the most prominent): Mental Disorder Affecting , . . {Indicate the General Medical Condition} (e.g., an Axis I disorder such as Major Depressive Disorder delaying recovery from a myocardial infarction) Psychological Symptoms Affecting . . . [Indicate the General Medical Condition] (e.g., depressive symptoms delaying recovery from surgery; a nxiety exacerbat ing asthma) Personality Traits or Coping Style Affecting .. , [Indicate the General M ed ical Condition] (e.g., pathological denial of the need fo r surgery in a patient with cancer; hostile, pressured behavior contributing to cardiovascular disease) Maladaptive Health Behaviors Affecting . .. [Indicate the General Medical Condi tion] (e.g., overeating; lack of exercise; unsafe sex) Stress-Related Physiological Response Affecting , , [Indicate the General Medical Condition] (e.g., stress-related exace rbations of ulcer, hypertension, arrhythmia, or tension headache) Other or Unspecified Psychological Factors Affecting . . , {Indicate the Gen eral Medical Condition] (e.g., interpersonal, cultural, or religious factors)
The following Medication-Induced Movement Disorders are included because of their frequent importance in 1) the management by medication of mental disorders or general medical cond itions; and 2) the differential diagnosis wi th Axis I disorders (e.g., Anxiety Disorder versus Neuroleptic-Induced Akathisia; catatonia versus Neurolep tic Malignant Syndrome). Although these disorders are labeled "medica tion induced," it is often difficult to establish the causa l relationship between medica tion
332.1
Neuroleptic-Induced Parkinsonism
exposure and the development of the movement disorder, especially because some of these movement disorders also occur in the absence of medication exposure. The term neuroleptic is used broadly i..!1 this manual to refer to medications w ith dopamineantagonist properties. Although this term is becoming outdated because it highlights the propensity of antipsychotic medications to cau se abnormal movements, the term neuroleptic remains appropriate. Although newer antipsychotic medications are less likely to cause Medication-Induced Movement Disorders, these syndromes still occur. Neuroleptic medications include so-caUed conventional or typical antipsychotic agents (e.g ., chlorpromazine, haloperidol, fluphenazine), the newer "atypical" antipsychotic agen ts (e.g., c1ozapine, risperidone, olanzapine, quetiapine), certain dopamine receptor blocking drugs used in the treatment of symptoms such as nausea and gastroparesis (e.g., prochlorperazine, promethazine, trimethobenzamide, thiethylperazine, and metoclopramide), and amoxapine, which is marketed as an antidep ressant. Medication-Induced Movement Disorders should be coded on Axis I.
332.1
Neuroleptic-Induced Parkinsonism
Parkinsonian tremor, muscular rigidity, or akinesia d eveloping w ithin a few weeks of starting or raising the dose of a neuroleptic medication (or after reducing a medication used to treat extrapyramidal symptoms). (See p . 795 for sugges ted research criteria.)
333.92
Severe muscle rigidi ty, elevated temperature, and other related finding s (e.g., d iaphoresis, d ysphagia, incontinence, changes in level of consciousness ranging from confusion to coma, mutism, elevated or labile blood pressure, elevated creatine phosphokinase [CPK]) developing in association w ith the use of neuroleptic medication. (See p . 798 for sugges ted research criteria .)
333.7
Abnormal positioning or spasm of the muscles of the head, neck, limbs, or trunk developi.ng within a few days of starting or raising the dose of a neuroleptic medication (or after reducing a medication used to treat extrap yramidal symptoms). (See p. 800 for suggested research criteria.)
333.99
Subjective complaints of restlessness accompanied by observed movements (e.g ., fidgety movements of the legs, rocking from foot to foot, pacing, or inability to sit or stand s till) developing w ithin a few weeks of s tarting or raising the dose of a neuroleptic medication (or after reducing a medication used to treat extrapyramidal symptoms). (See p. 802 for s uggested research criteria.)
333.82
Involuntary choreiform, athetoid , or rhythm ic movements (lasting at least a few weeks) of the tongu e, jaw, or extremities developing in association wi th the use of neuroleptic medication for a t least a few mon ths (may be for a shorter period of time in eld erly persons). (See p. 805 for suggested research criteria .)
333.1
Fine tremor occurring d uring attempts to maintain a posture that develops in association with the use of medication (e.g., lithium, antidepressants, valproate). (See p. 807 for suggested research criteria .)
99S.2
nus category is available for optional use by clinicians to code side effects of medica-
tion (other than movement symptoms) when these adverse effects become a main focus of clinical attention. Examples include severe hypotension, cardiac arrhythm ias, and p riapism.
Relational Problems
Relational problems include patterns of interaction behveen or among members of a relational unit that are associa ted w ith clinically significant impairment in functioning, or symptoms among one o r more members of the relational unit, or impairment in the hmctioning of the relational unit itself. The following rela tional problems are included because they are frequ ently a focus of clinical attention among individuals seen by health professionals. These problems may exacerbate o r complicate the management of a mental disorder or general medical condition in one or more members
V61 .9 Relati onal Problem Rel ated t o a Ment al Di sorder o r General M edical Co nditio n
737 \
of the relational unit, may be a re.sult of a mental disorder or a general medical condition, may be independent of other conditions that are present, or can occur in the absence of any other condi tion. 'Nhen these problems are the p rincipal focus of clinical atten tion, they sh ould be listed on Axis I. Othenvise, if they are present but not the principal focus of clinica l attention, they may be listed on Axis IV. The relevant category is generally ap plied to all members of a relational unit who are being treated for the problem .
V61.20
This category sh ould be used when the focus of clin ical atten tion is a pattern of interaction beh\'een parent and child (e.g ., impaired comm unication, overprotection, inadequate d iscipline) that is associated with clinically signifi cant impairment in individ ual or family functioning or the development of clinically significant symptoms in parent or child .
V61.10
This ca tegory should be used when th e foc us of clinical attention is a pattern of interaction behveen spouses or p artners characteri zed by nega ti ve communication (e.g., criticisms), distorted communication (e.g ., unrealistic expectations), or noncommunication (e.g., withdrawal) that is associated w ith clinically significant impairment in individual or family hmctioning or the development of symptoms in one or both partners.
V61.8
This category should be used when the focus of clinical attention is a p attern of interaction among siblings that is associated with clinically significant impairment in individual or family fWlCtioning or the development of symptoms in one or more of the siblings.
This section includes categories that s hould b e u sed w hen the focu s of clinical attention is severe mistreatment of one individual by anoth er through physical abuse, sexual abuse, or child neglect. These problems are included because they are frequently a focus of clinical attention among ind ividuals seen by health professionals. The appropriate V code applies if the focus of attention is on the perpetrator of the abuse or neglect or on the relational unit in w hich it occurs. If the individu al being evalua ted or treated is the victim of the abuse or neglect, code 995.52, 995.53, or 995.54 for a child or 995.81 or 995.83 for an ad ult (dep end ing on the ty p e of abuse).
V61.21
This category shouJd be used when the focus of clinical attention is ph ysical abuse of a child . Coding fl o te: Specify 995.54 iffoms of clinical attention is 011 tIle victim .
V61.21
This category should be used when the focus of clin ical atten tion is sexual abuse of a child. Codillg lIote: Specify 995. 53 iffOCIiS of clinical attentioll is 011 the victim.
V61.21
Neglect of Child
This category should be used w hen the fOCllS of clinical atten tion is child neglect. Coding IIo te: Specify 995.52 iffOCII5 of clinical attentiOfl is 011 tile vicUm.
iffoms of clinical attention is 0 11 tile perpetrator and abuse is by partner if focus of clin ical attentioll is OIl tile perpetrator and abuse is by persoll
other than partmr iffoclls of clinical attention is on the victim
739
iffoms of diniCflI atten tion is 011 tile perpetrator and abuse is by partller iffOCII S of clillical attelltioll is all ti,e perpetrator alld abllse is by perSOll
otller tllall partller iffocu s of clillical attelltioll is 011 tile victim
995.83
V15.81
This category can be used when the focu s of clinical attention is noncompliance w ith an important aspect of the trea tment for a mental disorder or a general medical condition. The reasons for noncompliance may include discomfort resulting from treatment (e.g., medication side effects), expense of treatment, d ecisions based on personal value judgments or religious or cultural beliefs about the advantages and disadvantages of the proposed trea tment, maladaptive personality traits or coping styles (e.g., denial of illness), or the presence of a mental disorder (e.g., Schizoph renia, Avoidant Personality Disorder). This category should be used only when the problem is sufficiently severe to warrant independent clinical a ttention.
V65.2
Malingering
The essen tial feature of Malingering is the intentional production of false or grossly exaggerated physica l or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, Malingering may represent adaptive behavior- for example, feigning illness while a captive of the enemy during wartime. Malingering should be strongly suspected if any combina tion of the following is noted: 1. Medicolegal context of presentation (e.g., the person is referred by an attorney to the clinician for examination) 2. Marked discrepancy behveen the person's claimed stress or disability and the objective findings 3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen 4. The presence of Antisocial Personality Disorder Malingering differs from Factitious Disorder in that the motivation for the symptom production in Malingering is an external incentive, whereas in Factitious Disord er external incentives are absen t. Evidence of an intrapsychic need to maintain the sick role suggests Factitious Disorder. Malingering is d ifferentiated from Con version Disorder and other Somatofonn Disorders by the intentional production of symp-
toms and b)' the obvious, external incentives associated with it. In Malingering (in contrast to Conversion Disorder), symptom relief is not often obtained by suggestion or hypnosis.
V71.01
Thi s ca tegory can be used when the foc us of d inical attention is adult antisocial behavior that is not due to a mental disorder (e.g., Conduct Disorder, Antisocial Personality Disorder, or an Impulse-Con trol Disorder). Examples include the behavior of some professional thieves, racketeers, or dealers in illegal substances.
V71.02
This category can be used when the focus of clinical attention is antisocial behavior in a child or adolescent that is not due to a men tal disorder (e.g., Cond uct Disorder or an Impulse-Control Disorder). Examples include isolated antisocial acts of children or adolescents (not a pattern of antisocial behavior).
V62.89
This category can be u sed when the focus of clinical attention is associa ted with bord erline intellectual fu nctioning, that is, an IQ in the 71-84 range. Differential diagnosis between Borderline Intellectual Functioning and Men tal Retardation (an IQ of 70 or below) is especially difficu lt when the coexistence of certa in mental disorders (e.g., Sch izophrenia) is involved. Coding no te: This is coded 011 Axis 11.
780.9
This category can be used when the focus of clinical attention is an objectively idel tificd decline in cognitive functioning consequent to the agi ng process thai is w ithin normal limits given the person's age. Individuals with this condition may report problems remembering names or appoin tments or may experience difficulty in solving complex problems. This category should be considered only aft er it has been d etermined tha t the cognitive impairment is not att ributable to a specific men tal disorder or neurological condition.
V62.82
Bereavement
This category can be used when the focus of dinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sa dness and associated symptoms s uch as insonmia, poor appetite, and weight loss). The bereaved individ ual typically regards the depressed mood as "normal," a lthough the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The dura tion a nd expression of "nomlal" bereavement vary consider-
V62.3
Academic Problem
741
ably among different cultural groups. The diagnosis of Major Depressive Disorder is generally n ot given unless the symptoms are s till presen t 2 months after the loss. However, the presence of cer tain symptoms t]lat are not characteris tic o f a "normal" grief reaction may be helpful in diffe re ntiating bereavement fro m a r-,'Iajor Depressive Episode. These include 1) guilt abou t things other than actions taken or not taken by the survivor at the time of the death; 2) thoughts of death o ther than the survivor fee ling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences othe r than thinking that he or she hears the voice of, or trans iently sees the image of, the deceased person.
V62.3
Academic Problem
This category can be u sed w hen the focus of clinical attention is an academic p roblem that is not due to a mental disorde r or, if due to a menta l disorder, is sufficiently se\'ere to warra nt indepe ndent clinical attention. An example is a pattern o f failing grades or of significant underachievement in a p erson with adequate intellectual capadty in the absence of a Learning or Communication Disorder or any other mental disorder that would account for the problem.
V62.2
Occupational Problem
This category can be used w hen the foc us of clinical atte ntion is an occupational problem that is not due to a mental d isorder or, if it is due 10 a mental disorder, is sufficien tly se vere to warrant indepe nden t clinical attention . Examples include job dissatisfaction and uncertainty about career choices.
313.82
Identity Problem
This category can be used when the focus of cHn ical attention is uncertainty a bout multiple issues relating to identity such as long-term goals, career choice, friend ship patterns, sexual orientation and behavior, mo ral values, and group loyalties.
V62.89
This category can be used w hen the focus of clin ical attention is a religious or spirituaJ problem . Examples include distressing experiences that involve loss or ques tioning of faith, problems associa ted with conversion to a new faith, or questioning of spiritual values tha t may n ot necessarily be related to an organized church or religious institu tion.
V62.4
Acculturation Problem
This category can be llsed when the focus of clinical attention is a p roblem involving adjustment 10 a differe nt culture (e.g., foUowing migration).
V62.89
This category can be used when the focus of clinical attention is a problem associated
with a particular developmental phase or some other life circumstance that is not due to a mental disorder or, if it is due to a mental disorder, is sufficiently severe to war rant independent clinical attention. Examples include p roblems associated with en tering school, leaving parental control, starting a new career, and changes involved in marriage, divorce, and retirement.
Additional Codes
300.9
There are several circums tances in which it may be appropriate to assign this code: 1) for a specific menta l disorder not included in the DSM-JV Classification, 2) when none of the available Not Otherwise Specified categories is appropriate, or 3) when it is judged that II nonpsychotic menial disorder is present but there is not enough information available to d iagnose one of the ca legories p rovi ded in the Classification. In some cases, the diagnOSiS can be changed to a specific d isorder after more information is obtained.
V71.09
' '''hen no Axis I diagnosis or condition is present, this should be indicated . There may or may not be an Axis n d iagnosis.
799.9
'A'hen there is insu fficien t in formation to make any diagnos tic judgment about an Axis I diagnosis or condition, this should be noted as Diagnosis or Cond ition Deferred on Axis L
V71.09
No Diagnosis on Axis II
When no Axis n diagnosis (e.g., no Personality Disorder) is present, this should be indicated. There mayor may not be an Axis I diagnosis or condition.
799.9
When there is insuffi cient infomlation to make any diagnostic judgment about an Axis II diagnosis, this should be noted as Diagnosis Deferred on Axis U.
743
Appendix A
T he purpose of these deci sion trees is to aid the clinician in understanding the organization and hierarchical structure of the DSM-JV Classification . Each decision tree starts with a set of clinical features. ,"Vhen one of these features is a prominent part of the p resenting clinical picture, the clinician can follow the series of ques tions to rule in or rule out various disorders. Note that the questions are on ly approximations of the diagnostic criteria and are not meant to replace them. The Psychotic Disord ers d ecision tree is the only one that contains disord ers that
are mutually exclusive (i.e., only one disorder from that section can be diagnosed in a given individual for a particular ep isode). For the other decision trees, it is important to refer to tJle individual criteria sets to determine when more than onc diagnosis may apply.
Con tellts
I. Differential Diagnosis of Mental Disorders
D.
m.
IV. V. VI.
Due to a General Med ical Cond ition Differential Diagnosis of Substance-Induced Disorders Differential Diagnosis of Psych otic Disorders Differential Diagnosis of Mood Disorders Differential Diagnosis of Anxiety Disorders Differential Diagnosis of Somatoform Disorders
Note: Prepared by Michael 13. Firs t, M.D., Allen Frances, MD., and Harold Alan Pincus, M.D.
745
746
A ppend ix A
t
Disturbance of
consciousness and a
No
A GENERAL
MEDICAL
CONDITION
DElIRIUM DUE TO
change in cognition
more than one etiology (e.g., substance and gene ral medical conditions)
No
ETIOLOGIES
etiologr (e.g.,
cerebrovasculilr
disease and Alzheimer's disease)]
No
No
~ NO
'Yes VASCULAR Evidence that cerebnwilscular DEMENTIA disease is etiologically related
to the d is turbance
No
Dis turbance due to central ne ncous system oondiUon or systemic condition known to cause dementi"
DEMENTIA DUE TO
No
Gradual onset and V" DEMENTIA OF TH E ALZHEIMER'S TYPE con tin uing cognltivt,! decline
I NO
~I DEMENTIA NOS
AMNESTIC DISORDER DUE TO A GENERAL MEDICAL CONDITION
747
Ve.
MEDICAL
CONDITION
No
I Yes
MOOD DISORDER
aUETO A
________________________________ cccc==c--------ANXIETY
DISORDER DU E TO A GENERAL
MEDICAL
CONDITION
No
Clinically significant Ve.
sexual d ysfunction cxd us in ,l)' due to a gene ral med ical conditi on
SEXUAL OYSFUNCTION
aUETO A
GENERAL MEDICAL
(ONOlTlON
No
DishJ rbance in siccp V" sufficiently se n :re to ' warran t ind epen dentl clinical attention
GENERAL MEDICAL
CONDITION
No
Catatonia
I Yes
CATATONICDUE TO DISORDER
A GENERAL
MEDICAL
CONDITION
No
Change in p revious ' Yes persona li ty pattern
PERSONALITY
No
Clinic<lUy signific.mt IYes sympt oms et iologic<lUy related to a general medical condition tha t d o not meet criteria for a specific Menta l Disorde r Due to a General Medical Cond iti on
No No menta l d isord er (symp toms that are not cliniCollly significant)
1 748
Appendix A
physiological effects
of a substance (i.e ., a d rug of abuse, a medication, o r a toxin)
A disturbance of
Ye s
cun5Cio usness a nd II change in cognition that are in excess o f that usually seen in intoxica tion o r withdrawal o1nd thai warra n t ind ependent clinical attention
! Evid ence that the INO~.1 Onset of d eliriu m ,Ve. disturbance has during w ithd rawal
more than one etiol ogy (e.g.,
SUBSTANCEINDUCED
WITHDRAWAL DElIRiUM
from a substance
No
Ve.
No
SUBSTANCEINDUCED
INTOXICATION
DELIRIUM
DELIRIUM DUE
TO MULTIPLE ETIOLOGIES
Yestol At INs! one
I Yes
E\'idence th at the d is turba nce has mol\' than one etiology (e.g._ substance and gener~ l medic,ll cond ition)
No
No
No
V"
J
DEMENTIA DU E TO MULTIPLE ETIOLOGIES
749
De!USiOT15 or hallucinatioT15 predomin.:ate,.l1l' in \ Yes excess of that usually seen in intoxication or WithdrilW~ !, and warrant indept'ndent clinical dttention
I
A
SUBSTANCEIN DUCED PSYCHOTIC DISORDER Specify if omet during intoxkClt ion o r withdra w al
mood di> turbance predominates, is in excess ri\~~"~;b.~;;;!J.;;i,~~",~~~~CV~'"''-________________~ of tha t usually seen in intoxicdtion or withdrawal, and warrants independent clinical attention
~NO
~NO
SUBSTAN CEINOUCED MOOD DISORDER Specify if onset during into xica tion or wi thdrawClI
Clinicallr significant sexual dysfunction exclusively due to a s ubstance, is in excess of Ih.:at U5Ually 5el'n in intoxication, and warrants indept'ndi!nt dinica! attenti on
No
I Yes
Disturbance in sleep thai is suffiOi!ntly sen~re to I I,'arrant indept'ndenl clinical attention and is in excess of th~t usuallr seen in intoxication o r wilhdrawal
V"
,
[)cl'elopmen! of a reversible syndrome due 10 recen l usc of a subs tance
No
V" V V"
SUBSTANCE INTOXICATION
SUBSTANCE WITHDRAWAL
Clinically sign ificant symploms due to a subs tance that do not meet criteria for one of the Substance-Induced Disorders
No Substance-Induced Disorder (subs tance-induced symptoms that an! not clinically signific'lIlt)
750
Append ix A
v.,
PSYCHOTIC DISORDER
OUETOA
GENERAL MEDICAL
CONDITION
No
Due to the direct
V.,
physio1ogiCill effects
of a subs tance (e.g., a drug of abuse, a medication, or a toxin)
No
Symptoms of acth"e phase of Schizophrenia, lasting at least I month
Yo>
No
No
To lal duration of mood episodes has been brief relath"e to duration of active a nd residual periods
V.,
Yo>
SCHIZO
PHREN IA
No
No
I
SC HIZO
PH REN IFORM
DISO RDER
V.,
MOOD
DISORDER
WlTH
Ves l
Total duration of mood episodes has been brief relative to duration of delusional pt'riods
t vel.1Apart from
delusions, functioning not markedly impaired
V ..
DELUSIONAL DISORDER
No
No
No
Delusions occur only during mood episodes
No
IYes
MOOD DISORDER WITH PSYCHOTIC FEATURES (see Mood Disorders tree)
I Yes
No
....
752
Appendix A
A GENERAL MEDICAL
CONDITION
No
Due to the d irect physiological effects of a 5ubst.mce (i.e., a drug of abuse, a medica tion, o r a loxin)
Yeo
SUBSTANCE-INDUC ED
MOOD DISORDER
No
rklennine type o f p resent and pas t mood epi>odes
Yeo Ele\'ated, expansi \'e, or MANIC EPISODE irritable mood, a t leasl l- week duration; marked impairment or hospitalization
No
Elevated, e;.;paru;in!, o r irritable mood, at least +day duution; changes obse,,'able
HYPOMANIC EPISODE
~'"'M':W'
At least 2 weeks of
Yeo
No
Yeo MIXE D EPISOD E Criteri a met for Manic Episode and Major Depressh"e Episode nearly eve ry day for at least 1 week
No
Has e\"er had a ~1ANIC EPISODE or a MIXED EPISODE
~s
Psychotic symptoms occur at times other tho during Manic m o r 1I..tixed Episodes
IN.O
81POLAR I DlSOROER
No
Ves
Occurred exclusively during Schizoaffective Disorder (revie w Psychotic Disorde~ tree)
J~
IYes
~IHi~;;-;'~';";:Iu;;;;d"'~HYPOii;;ro;:';;'A"N'""C:~!v!.!,_____ _ ____--+. 1
EPISODE and al 11.'4>1 one !\lAJOR DEPRESSIVE EP ISODE
BIPOLAR
II DISORDER
No
2+ r ears of h)'pomanic symp loms and periods of dep'S~ mood
No
Clirtically significMlI . maniC / hrpomanlC 5)'1np oms lhill do nOI meel criteria for a ,-specific Bipolar Disorder
_Ve"'' -_ _ _ __ __ _ _ _
No
Has eve r had a MAJOR DEPRESSIVE EPISODE IYes Psychotic symptoms occur at tim es other Ihan during Major Depressive Episodes
L ~a
No
TYPE
No
DEPR ESSIVE DISO RDER NOS (superimposed on Psychotic Disorder)
Depressed mood, more days than not, for at least 2 years with associated symptoms
, V. .
DYSTHYMIC DISORDER
I
V" ADJUSTM ENT DISORDER WITH DEPRESSED MOOD
No
();opressed mood not meeting criteriil (or one of ilbo'-e ~Iood Disorders that develops in response to a st'Ssor
I
DEPRESSIVE DISORDER NOS
Clinically depress ive symptoms that do not meet criteria for a 5pecific Mood Disorder
signific~~~,~_._:_-LVY'.''-------------
No
No
754
Append ix A
arousal
V"
,No
Due to the direct phpiol ogicaJ effecls of a substance (e.g., a drug of abuse, a mooicanon, a toxin)
V.,
SUBSTANCE-INDUCED
ANXIETY DISORDER
No
Recurrent UJlexpec::led Panic
No
Agoraphobia, i.c ., anxiety .lbout being in places from which escape mig ht be difficult o r emba rrassing in the e\'l.'n t of M\'ing panic-like symptoms
V"
DISOROER
J _No
Anxicty concerning separoltion from ;H!ilchment figu~'S with onset in childhood
! Yes
No
Feilr of humiliilti on or embarrassment in social or perfonnance situations
No
Fear cued by object or situation
V"
~N o Obsessions or compulsions
I
V"
SPECIFIC PHOBIA
OBSESSIVe--COMPULSIVE DISORDER
755
~
i!Illcietyand worry plus anxie ty sym ptoms
No
~-Iood
or Psychotic Disorder
Yes
jYes
;-+
,
No
Reexperiencing of event, increased arousal, and avoidance of stimuli associa ted with traumati c el'ent
T No
.,Yes
r
No
WITH ANXIETY
No
Clinically signifka nt symptoms tha t do not met'! criteria fo r a specific All>'iety Disorder
,I
V!e~'!--_
No
No Anxiet)' Disorder (symptoms of fear, anxiety, or avoidance that a re not clinically Significant)
756
Append ix A
appeuance
Physical complaints ~Y~5 SpOOfic G&~ERJ.\ l are fully explained MEDICAL by a gene ral COl'>.'OmON (no medical condi tion Som"tofonn and complain ts are Disorde r) not in excess of expec ted
AFFECTING MEDICAL
CONDITION
No
Physical symp toms are intentionally produced
I Yes
FACTITIOUS
DISORDER
No
INo
I
History of multiple ph)'5 ical complaints wi th at least "\ pain symptoms, :2 gas trointestinal symptom5, I sexual symptom, and 1 pseudoneurologica l symptom
MALINGERING
V"
SOM ATIZATION
DISORDER
No
S}mptom or deficit affecting \'olunta ry
motor or 5ef\50!y ful\(lion
V ..
CONVERSION
DISOR DER
No
Symptom or deficit a ffecting sexual funcliorung
SEXUAL DYSFUNGI ON
Pain is forus of clinical alhmlio", and psychological factors ha'-e important role
PAIN DISORDER
No
V Other phys ical complaints las ting at least 6 months
.No
757
IYes
'-+
No
I
I Yes
No
HYPOCHONDRIAS IS
y"
s...e Psychotic
Disorders tree Preoccupation with imagined ddect in appearance
BODY DYSMORPHIC DISORDER (if delusional, also see Psychotic Diso rde rs tree)
~NO
Clinically significant SOn1a toform symptoms that do not meet cri teria for a specific Som.ltoform Disorder
Yo>
No
No Somaloform Disorder (SOn1ato form symp toms that are not clinically significan t)
Appendix B
T h is appendix contains a munber of proposals for new categories an d axes that were suggested for possible indusion in DSM-IV. The OSM IV Task Force and Work Groups s ubjected each of these proposals to a careful empirical review and invited wide commentary from the field . The Task Force determined that there was insufficien t information to warrant inclusion of these proposals as official categories or axes in DSM-IV. The items, threshold s, and dura tions contained in the research criteria sets are in tended to provi de a common language for researchers and clinicians w ho are interested in s tudying these disorders. It is hoped that such research w ill help to determine the possible utility of these proposed categories and will result in refinement of the criteria sets. The specific thresh olds and durations were set by expert consensus (informed by literature review, data reanalysis, and field-trial res ults when such information was available) and, as such, should be considered tentative. It would be highly desirable for researchers to study alternative items, thresholds, or durations whenever trus is possible. The following proposals are included in this appendix:
Postconcussional disord er Mild neurocognitive disorder Caffeine w ithdrawal Alternative dimension al d escriptors for Schizophrenia Postpsychotic depressive disorder of Schizopluerua Simple deteriorative disorder (simple Schizophrenia) Premenstrual dysphoric disorder Alternative Criterion B for Dysthymic Disorder Minor depressive disorder Recurrent brief depressive disorder Mixed anxiety-depressive disorder Factitious disorder by proxy Dissociative trance d isorder Binge-eating di sorder Depressive personal ity disorder Passive-aggressive personality disorder (negativistic persona]jty disorder)
,
759
760
Appendix B
Medication-Induced Movement Disorders Neuroleptic-Induced Parkinsonism Neuroleptic Malignant Syndrome Neuro leptic-Ind uced Acute Dystonia Neuro leptic-Induced Acu te Akathisia Neuroleptic-Ind uced Tardive Dyskinesia Med ication-Ind uced Poshual Tre mor Medication-Ind uced Movemen t Disorder Not O therwise Specified
(Note: These ca tegories are included in the "OUler Cond.itions That May Be a Focus of Clinica l Attention" section. Text and research criteria sets for these conditions are included here.)
Defensive FlUlction ing Scale Global Assessment of Relational Functioning (GARF) Scale Social and Occup ational Functioning Assessm ent Scale (SOFAS)
Postconcussional Disorder
Fea tures
The essential feature is an acquired impairment in cogni tive func tioning, accompanied by specific ne urobe havioral sym p toms, that occu rs as a cons eque nce of closed head injury of s u ffi cient severity to produce a significant cerebra l concussion . The ma nifes ta tions of concussion include loss of consciousness, pos ttraumatic amneSia, and less com monly, posttrau ma tic onset of seizu res. Sp ecific approaches for defining this c rite rion need to be refin ed by furth e r resea rch. Although there is insu fficient e vide nce to estab lish a definite th res hold for the severity of the closed head injury, speci fi c criteria have been suggested , for example, two of th e following: 1) a period of u nconsciousness las ting more th an 5 minutes, 2) a p eriod of p osttrauma tic amnesia that lasts more than 12 hours after the closed head inju ry, or 3) a new onset of seizures (or ma rked worsening of a preexis ting seizu re d isord er) tha t occurs within the first 6 mon ths afte r the closed head inju ry. There m us t also be docume nted cognitive deficits in either a tten tion (concen tration, s hiftin g focu s of atten tion, pe rforming sim ultaneous cognitive tasks) or memory (learning or recalling information). Accompanying the cognitive d isturbances, there must be three (or more) sym p toms tha t are present for at leas t 3 months following the closed head injury. These includ e becoming fatigued easily; disordered s leep; headache; vertigo or d izziness; irritabi lity or aggress ion on little or no p rovoca tion; a nxiety, d epression, o r affective labili ty; apa thy or lack of spontaneity; and other changes in personality (e.g., social or sexual inapprop ria ten ess). The cognitive d is turbances and the somatic and behavio ral symptoms develop a fte r the head trauma has occurred or represe nt a s ig nificant worsening of p reexis ting symptoms. llle cognitive a nd n eurobe hav io ral sequelae a re accom panied by significant impairmen t in social o r occu pational fun ctioning and represen t a significant decline from a previous level of fun ctioning. in the case of school-age child ren, the re may be Significant worsening in acad emic ach ieveme nt dating from the tra uma . This proposed disorder shou ld not be considered if the individ u al's symptoms meet the criteria for De me ntia Due to Head Tra u ma or if the sym ptoms are bette r accounted for by anothe r menta l disorder.
761
becoming fat igued easi ly disordered sleep headache vertigo o r dizz iness irritability or aggression on little or no provocation anxiety, de pression, or affective la bility (7) changes in personality (e .g., social or sexua l inappropriateness) (8) apathy o r lack of spont aneity
1 762
Append ix B
F. The symptoms do not meet criteria for Dementia Due to Head Trauma and are not better accounted for by another mental disorder (e.g., Amnestic Disorder Due to
Head Trauma, Personality Change Due to Head Trauma).
Features
Theesscntial feature is the development of impa irment in neurocognitive functioning that is due to a general medical condition. By d efinition, the lcvel of cognitive impairment and the impact on e\feryday functioning is m ild (e.g., the individua l is able to partially compensate for cognitive impairment w ith additional effort). individuals w ith th is condition have a new onset of deficits in at least two areas of cognitive functioning. These may include dis turbances in memory (1eaming or recalling new information), execu tive fu nctioning (e.g., planning, reasoning), attention or sp eed of information p rocessing (e.g., concentration, rapidity of assimilating o r analyzing information), perceptual motor abilities (e.g., integrating visual, tactile, o r auditory infor mation with motor activ ities), or language (e.g., word-fi nding difficu lties, reduced fluency). The report o f cognitive impairment must be corroborated by the results of neuropsychological tes ting or bedside s tandardized cognitive assessment techniques. Furthermore, the cogni tive d efi cits cause marked djstress or interfere with the ind ividual's social, occupational, or other important areas of funct ioning and represent a decline from a previou s level of functioning . The cogni tive disturbance docs not meet criteria for a delirium, a dementia, or an amnestic disorder and is not better accounted for by another mental d isorder (e.g., a Substance-Related Disorder, Major Depressive Disorder).
Associat ed Features
The associated fea tures depend on th e underlying general medical condition. In the case o f certain chronic disorders (e.g., hypoxemia, electroly te imbalances), the cognitive profile is usually one of a generalized reduction in all cognitive functions. Some neurological and other general medical conditions produce pa tterns of cognitive impairment that suggest more "subcortical" brain in volvement (i.e., d isproportionate impairment in the abmty to concentra te and learn new facts and in the speed and effici ency of p rocessing information). These include the early phases of Hlmting ton's
763
disease, HIV-associated neurocogni tive disorder, and Parkinson's disease. O ther conditions (e.g ., systemic lupus erythematosu s) are m ore frequen tly associated with a multifocal or patchy pattem of cognitive loss. The EEG may show mild slowing of backgrOlUld activity or disturbance in evoked p otentials. Mild cognitive impairment, even in cases of early Alzheimer's disease, is frequently present without specific changes on neuroanatomical studies using magnetic resonance imaging (MRI) or compu ted tomography (CT). Abn ormalities are more likely to be present in functional brain imaging studies (single photon emission computed tomography [SPECf), positron-emission tomography [PET], hmctional ~'lRI). The course depends on the underlying etiology . in some instances, the cognitive impairment slowly worsens so tnat ultimately a di agnosis of dementia becomes appropriate (e.g ., early phases of Alzheimer's disease, HWltington's disease, and other slowly progressive neurodegenerative conditions). In other instances, the disturbance may improve slowl}', as in gradual recovery from h yp othyroidism . In some instances, cognitive dis turbances due to severe metabolic derangements or infectious diseases m ay resolve partially but be dlaracterized by a residual impairment that is permanent.
Differential Diagnosis
In DSM-IV, individuals whose p resentation meets these research criteria would be diagnosed as having Cognitive Disorder Not Othenvise Specified. Although there is no dear boun dary between mild neurocognitive disorder and dementia, mild neurocognitive disorder has less cogniti ve impairment and less impact on daily activities, and memory impairment is not a requi rement. Mild neurocognitive disorder may be confused w ith a slowly evolving d elirium, especially early in its course. Mild neurocognitive disorder can be dis tinguished from an amnestic disorder by the requirement that there be cognitive impa irment in at least two areas. NWd neurocognitive disorder should not be considered if an indi vidua l's symptoms meet criteria for a Substance-Related Disorder (induding medication side effec ts) . In such cases, the appropriate Subs tance-Related Disorder Not Otherwise Sp ecified s hould be diagnosed . Pos tconcussion al disorder, another ca tegory listed in this appendix (see p. 760), is distinguished from mild neurocognitive disorder by the presence of a specific pattem of symptoms and a specific etiology (i.e., closed head injury). Mild neurocognitive disturbances are a common associated feature of a number of mental disorders (e.g., Major Depressive Disorder). Mild neurocogniti ve disorder should only be considered if the cog nitive impairment is better accounted fo r by the direct effects of a general medical condition than by a mental di sorder. Individuals with Age-Related Cognitive Decline may have similar levels of cognitive impairmen t, but the d ecline is considered to be part of the normative aging process rather than attributable to a general medical condi tion. individuals m ay report subjective complaints of impairmen t in cognitive functioning that cannot be corroborated by neuropsychological testing or are judged not to be associa ted w ith a general medical condition. This proposed disorder should not be considered for such presen tations.
Append ix
(1) memory impairment as ide ntified by a reduced ability to learn or recall information (2) disturbance in executive functioning (Le., planning, organizing, sequencing, abstracting) (3) disturbance in attention o r speed of information processing (4) impairment in perceptual-motor abilities (5) impairment in language (e.g ., comprehension, word fi nding) B. There is objective evidence from physical examination or laboratory findings (including neuroimaging techniques) of a neurological or general medical condition th at i~ judged to be et iologically related to the cognitive di sturbance.
c.
There i~ evidence from neuropsychological testing or quantified cognitive assessment of an abnormality or decline in performance.
D. Th e cognitive deficits cause marked distress or impairment in social, occupational, or other important areas of fun ctioni ng and represent a decl ine from a previous level of functioning . E. The cognit ive disturbance does not meet criteria for a delirium, a dementia, or an amnestic disorder and is not better accounted for by another mental disorder (e.g., a Substance-Related Disorder, Major Depressive Disorder) .
Caffeine Withdrawal
Features
The essential feature is a characteristic withdrawal syndrome due to the abrupt cessation of, or reduction in, the use of caffeine-containing products after p rolonged daily use. The syndrome includes headache and one (or more) of the following symptoms: marked fatigue or drowsiness, m arked anxiety or depression, or nausea or vomiting. These symptoms appear to be more prevalent in individuals wi th heavy use (SOD mg / day) but may occur in individu als w ith light use (100 mg / day). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must not be due to the direct ph ysiological effects of a general medical condition and must not be better accounted for by another mental disorder.
Associated Features
Associa ted symptoms include a strong desire for caffeine and worsened cognitive performance (especially on vigilance tasks). Sym p toms can begin within 12 hours of
cessation of caffeine u se, peak aro~d 24-48 hours, and last u p to 1 week. Some individuals may seek m ed ical treatment for these symp toms without realizing they are due to caffeine w ithdrawal.
B Abrupt cessat ion of caHei ne use, or reduction in the amount of caHeine used, closely . followed by headache and one (or more) of the following symptoms:
(1) marked fatig ue or drowsiness
cial, occupational, or other important areas of functioni ng . D. The symptoms are not due to t he direct physiological eHects of a general medical (Qndition (e.g., migraine, viral illness) and are not better accounted for by another mental disorder.
766
Appendix B
time, whereas this is less true for symptoms across fac tors. For example, as delusions become more severe, ha llucinations tend to become more severe as well . In contrast,
the severity of negative or disorganized symptoms is less related to the severity of hallucinations or delusions. One model for understanding the clinical heterogeneity of Schizophrenia suggests that each of these three dimensions may have different underlying pathophysiologica l processes and treatment responses. Various combinations of severity on the three dimensions are encountered in clinical p ractice, and it is relatively uncommon for one dimension to be present in the complete absence ofbotr of the others. The following is a system for applying these dimensions in research an( clinical studi es.
absent, mild, moderate, severe for each dimension. The prominence of these dimensions may be specified for either (or bot h) the current episode (i.e., previous 6 months) or the lifetime course of the disorder. psychotic (hallucinations/delusions) dimension: describes the degree to which hallucinations or delusions have been present disorganized dimension: describes the degree to which disorganized speech, disorganized behavior, or ina ppropriate affect have been present negative (deficit) dimension : describes the degree to which negative symptoms (i.e., affective flattening, alogia, avolition) have been present. Note: Do not include symptoms that appear to be secondary to depression, medication side effects, or hallucinations or delusions.
Two examples that include the DSM-IV subtype, course specifiers, and the proposed dimensional approach are
Example 1 295.30 Schizophren ia, Paranoid Type, Continuous Current: Wi th severe psychotic dimension Wi th absent disorganized d imension With moderate negative dimension
Ufetime: With mild psychotic dimension With absent disorganized d imension With mild negative dimension
Example 2 295.60 Schizophrenia, Residual Type, Episodic With Residual Symptoms Current: mild psychotic d imension With mild disorganized dimension \"' ith mild nega tive dimension
''''ith
Criteria Sets and Axes Provided for Further Study Lifetime: With moderate p sychotic dimension \N ith mild disorganized dimension With mild negative dimension
767
Associated Features
As compared with individuals with Schizophrenia withou t postpsychotic depressive episodes, these individuals are more likely to be living alone and to have fewer social supports. Other associated features may include a larger number of previous hospitalizations, history of psychotic relapses while being treated with an tipsychotic medications, insidious onset of psychotic episodes, p rior episodes of depression, and prior suicide attempts. There may be recent losses, undesirable life events, or other stressors. Reported prevalence rates vary, but up to 25% of individuals with Schizophrenia have been d escribed as having this condition sometime in the course of thei r illness. These individuals appear more likely to relapse into a psychotic episode or to be rehospitalized than those without depression . Individual s with Schizophrenia who also have firs t-degree biological relatives with histories of Major Depressive Disorder may be at higher risk for postpsychotic depressions. This condition is associated with suicidal ideation, suicide attempts, and completed suicides.
Differential Diagnosis
In DSM-JV, individuals whose presentation meets these researdl criteria would be diagnosed as having Depressive Disorder Not O thenvise Specified. Mood Disorder Due to a General Medical Condition is dis tinguished from this disturbance by the fac t that the depressive symptoms are due to the d irect physiolog-
Appendix B ical effects of a general medical condition (e.g., hypothyroidis m). Sub s tance-I n duced Mood Dis order is dis tinguished from this disturbance by the fact that the depressive symptoms are due to U,e direct physiological effects of a drug of abuse (e.g., alcohol, cocaine) or the side effects of a medication . Individuals with Schizophrenia a re often on maintenance neurolep tic medica tions, which can cause d ysphoria or Medicationlnd\lced Movement Disorders as side effects. These s ide effects can be confused with depressive sympto ms. Neuroleptic-In duced Pa rkin sonis m w ith akinesia (see p. 792) is cha racterized by a reduced ability to initia te or sustain behaviors, which can lead to a lack of sp ontaneity or anhedonia . Neurole pt ic-Indu ced Acu te Ak a thisia (see p. 800) may be mis taken for anxiety or agitation, a nd d epressed mood or s uicidal ideation may be associa ted . Adjus ting the m edica tion type or d ose may assist in reducing these side effects and clarify ing the cause of s uch symptoms. The di ffere ntial d iagnosis between postpsychotic depressive symptoms and the n egative symptoms of Schizophrenia (i.e., avolition, alogia, affective flattening) may be particularly difficult . Negative symptoms must be distinguished from the other sym p toms of depression (e.g ., s adness, g uilt, shame, hopelessness, helplessness, and low self-esteem). In Sch izoaffective D is ord er and Mood D isorder With Psych otic Featu res, there mus t be a substantial period of overlap between the full psychotic episode a nd the mood e p isode. In contrast, this proposed disorder is diagnosed only d uring the residual phase of Schizophrenia. D e m oralization may occur during the course of Schizophre nia but sho uld not be considered pos tpsychotic depression unless the full criteria for a Major Depressive Episode are met. Adjustment Disorder With Dep ressed Mood is dis tinguished from postpsychotic depressive disorder of Schizophre nia because the depressive symptoms in Adjustment Di sorder d o not meet the c riteria fo r a Major Depressive Episode.
disorder of Schizophrenia
A.
Criteria are met fo r a Major De pressive Episode. Note: The Major Depressive Episode must include Criterion Al : depressed mood. Do not include symptoms that are better accounted for as medication side eHects or negat ive symptoms of Schizophrenia.
B. The Major Depressive Episode is superimposed on and occurs only during the residual phase of Schizophrenia.
C. The Major Depressive Episode is not due to the direct physiolog ical eHects of a sub-
Associated Features
Any of the features o f Schizoid or Schizotypal Personality Di so rder may be present. ~'lost common are peculiarities of grooming and behav ior, lapses in hygiene, overinvestment in odd ideas, or unusual perceptua l experiences such as illusions. This proposed disorder may occur in adolescents and adults of both sexes. Good estimates of prevalence and incidence are not available, but it is dear that the di sorder is rare. The course, at least for the firs t few yea rs, is progressively downhill, with prominent deterioration of functioning. This deterioration in functioning resembles the characteristic course of Schizophrenia and distinguishes this condi tion from Sdlizoid and Schizotypal Personality Disorders. Sy mptoms meeting Cri terion A for Schizophrenia may emerge, at which time the diagnosis is changed to Schizophrenia . In these instances, this pattern proves to have been a prolonged prodrome to Schizophrenia . In other cases this pattern recedes in severity, as can happen w ith Schizophrenia. For the majority of individuals, the course is co ntinuous, with deterioration occurring within the first few years after prodromal symptoms and then plateauing to a marginal and reduced, but stable, functional capacity.
770
Append ix B
This pattern should be considered only aft er all other possible causes of deterioration in fun ctioning have been ruled out. nus pattern is d istinguished from the disorde rs included in the "Schizophrenia a nd O ther Psychotic Disorde rs" section by the absence of prom inent positive psydlOtic sym p toms. These d isorders include Sc hizophre n ia, Schizoaffective Diso rd er, Schizop hren iform Disord er, Bri ef Psych otic Disorder, D elusional Disord er, Shared Psychotic Disord er, and Psychotic Disorder Not Oth erwise S pecified, all of w h ich require a t least one p ositive sy~ptom for some period of time. TIlis proposed disorder is d istinguished from Schi zoid and Schizotypal Person ali ty D isorde rs as well as other Person ality Disord ers by the requiremen t o f a clear change in persona lity and ma rked d eterioration in func tioning. In contrast, the Personality Disorders represen t lifelong patterns w ithou t progressive d eterioration. Mood Di sorders may m imic the apathy and anhed onia o f simple deteriorative d isorder, bu t in a Mood Disorder depressive affect (sadness, hopelessness, helplessness, painful guilt) is experienced, and the course tends to be episod ic. Furthermore, in simple d eteriora tive d isorder, there is a sense of emptiness rather than a painful o r prominently dep ressive mood, and the course is continuous and progressive. The d istinction can be more difficult w ith Dysthym ic Disorder, in which the cou rse may also be continuous and in w hich vegetative s}' mptoms and painfully depressive mood may not be prominent. This p roposed disorder may mim ic chronic Substance Dependence and should only be considered if the personali ty change and deterioration precede extensive su bstance use. Personali ty Change Due to a General Medical Co ndit ion is d istinguished by the presence of an etiological general med ical cond ition. The cogniti ve impairment of simple deteriorative disorder may be mistaken for Men tal Re tardation or demen tia. Mental Retardation is distinguished by its typical onset in infancy or childhood. Dementia is d istinguished by the presence of an etiological general medical condition or substance lise. Perhaps the most difficu lt differential djagnosis is with no men tal disorder. Simple deteriorative disord er o ft en leads a person to become a marginal member of society. It does not follow, however, that marginal members o f society necessarily have th is p roposed disorder. The d efining fe atures of simple deterio rative d isorder involve negative symptoms, w hich tend to be more on a continuu m with normality than are positive symptoms and wh ich may be mimicked by a variety of factors (see the relevant discussion in the "Schizophrenia" section, p . 301). Therefore, special cau tion must be taken no t to apply this p roposed d isorder too broa dly.
771
(1) marked decline in occupational or academic functioning (2) gradual appearance and deepening of negative symptoms such as affective flattening, alogia, and avolition (3) poor interpersonal rapport, social isolation, or social withdrawal B. Criterion A for Schizophrenia has never been met.
e.
The symptoms a re not better accounted for by Schizotypal or Schizoid Personality Disorder, a Psychotic Disorder, a Mood Disorder, an Anxiety Disorder, a dementia, or Menta l Retardation and are not due to the direct physiological effects of a substance or a genera l medical condition.
772
Appendix B
Typically, the symptoms are of comparab le severity (but not duration ) to those of another mental disorder such as Major Depressive Episode or Generalized Anxiety
Disorder and must cause an obvious and marked impairment in the ability to function socially or occupationally in the week prior to m enses. Impairment in social functioning may be manifested by marital discord and problem s with friend s and family. It is very important not to confuse long-standing ma rital or job problems with the d ysfunction that occurs only premenstrually. There is a great contrast beh\'een the woman's depressed feelings and difficulty in fu nctioning during these days and her mood and ca pabilities the rest of the mon th . These symptoms may be superimposed on another disorder but are not merely an exacerbation of the symptoms o f another disorder, such as Major Depressive, Panic, or Dysthymic Disorder, or a Personality Disorder. The presence of the cyclical pattern of symptoms must be confirmed by at least 2 consecutive months of prospective da ily symptom ratings. Daily sym p tom ratings must be done by the woman and can also be d one by someone with wh om she lives. It is important that these diaries be kept on a daily ba sis rather than composed ret.rospectively from memory.
Associated Features
Frequently there is a history of prior Mood and Anxiety Disorders. Delusions and hallucinations have been described in the la te luteal phase of the menstrual cycle but are very rarc. Whether they represent an exacerbation of a preexisting mental d isorder or instead are symptomatic of Premens lTual Dysphoric Disorder is unknown. Premenstrually related mood and somatic symptoms tend to run in families and are at least in part hereditary. Although women w ith the combination of d ysm enorrhea (painful menses) and premenstrual d ysphoric disorder are somewhat more likely to seek treatment than women with only one of these conditions, m ost women w ith either of the conditions d o not have the other condition. A w ide range of general medical conditions may worsen in the premenstrual or luteal p hase (e.g., mig raine, asthma, allergies, and seizure disorders). There are no sp ecific laboratory tests that are d iagnostic of the disturbance. However, in several small preliminary studies, certai n laboratory findings (e.g., serotonin or melatonin secretion patterns, sleep EEG findings) have been noted to be abnormal in groups of women w ith this proposed d isorder relative to con trol subjects. It is estimated that at least 75% of women report minor or isolated premenstrual changes. Limited studies suggest an occurrence of " premenstrual s}'Tldrome" (variably defined) 0200/.,.-50"lo, and that 30/0-5"10 of women experience symptoms tha t may meet the criteria for this proposed d isorder. There has been very little system.ltic study on the course and stability of this condition. Premenstrual symptoms can begin at any age after menarche. Although the majority of women whose symptoms meet research diagnostic cri teria for this p roposed disorder and participate in researd studies are in their early to mid-30s, women across the reproductive age s pan repor clinically significant premenstrually related symptoms. Although symptoms do not necessarily occur every cycle, they are present for the majority of the cycles. Some months the symptoms may be worse than others. Women commonly report that their symptoms worsen with age until relieved by the onset of menopause.
773
Differenti a l Di agnosis
In DSM-IV, individuals whose presen tation meets these research criteria would be diagnosed as having Depressive Di sorder Not O therwise Specified. The transient mood changes tha t many women experience around the time of their period should not be considered a mental d isorder. Premenstrual d ysphoric d isorder shou ld be considered only when the symptoms markedly interfere with work or school or with usual social acti vities and rela tionships with others (e.g., avoidance of social activities, d ecreased productiv ity and efficiency at WOrk or school). Premenstrual d ysphoric disorder can be d istinguished from the far mare common "premenstrual syndrom e" by using prospective d aily ra tings and the strict criteria listed below. It differs from the "premenstrual syndrome" in its characteristic patlern of symptoms, their severity, and the resulting impai rment. Premenstrual d ysphoric d isorder mu st be d istinguished from the premenstrual exacerbation of a current m ental disorder (e.g., Mood Disorders, Anxiety Disorders, Somatoform Disorders, Bulimia Nervosa, Substance Use Disorders, and Personality Disorders). In such situations (which a re fa r more common than premenstrual dysphoric disorder), there is a premenstrual worsening of the symptoms but the symptoms persist throughout the menstrual cycle. Although this condition should not be considered in women w ho are experiencing only a premenstrual exacerba tion of another mental disorder, it can be considered in addition to the d iagnosis o f another current mental d isorder if the woman experiences symptoms and changes in level of functioning that are ch aracteristic of premenstrual d ysphoric disorder and are markedly d ifferen t from the symptoms experienced as part of the ongoing disorder. Some individ uals w ith g en eral medical condition s may p resent w ith dysphoria and fatigue that are exacerba ted d uring the p remenstrua l period. Examples include seizure disorders, thyroid and other endocrine disorders, cancer, systemic lu pus erythematosus, anemias, endometriosis, and various infections. Attempts shouJd be made to distinguish these general medical conditions from premenstrua l d ysphoric disorder by h istory, labora tory testing, or physical exam in ation.
774
A ppendix B
toms were present for most of the time during the last week of the lutea l phase. began to remit within a few days after the onset of the follicu lar phase. and were absent in the week postmenses, with at least one of the symptoms being either (1). (2). (3). or (4):
(1) markedly depressed mood, fee lings of hopelessness. or self-deprecating
(2) (3)
thoughts marked anxiety, tension, feelings of being " keyed up," or "on edge" marked affective lability (e.g_, feeling suddenly sad or tearful or increased sensitivity to rejection) persistent and marked anger or irritability or increased i nterpersonal conflicts decreased interest in usual activities (e.g., work, school, friends, hobbies) subjective sense of difficulty in concentrating lethargy, easy fatigability, or marked lack of energy marked change in appetite, overeating, or specific food cravings hypersomnia or insomnia a subjective sense of being overwhelmed or out of control other physical symptoms, such as breast tenderness or swell ing, headaches, joint or muscle pain, a sensation of "bloating," weight gain
Note: In menstruating females, the luteal phase corresponds to the period between ovulation and the onset of menses, and the follicula r phase begins with menses. In nonmenstruating females (e.g., those who have had a hyst erectomy), the timing of luteal and follicular phases may require measurement of circulating reproductive hormones. B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g ., avoidance of social activities, decreased pro, ductivity and efficiency at work or school).
Criteria Sets a nd Axe s Provided fo r Furthe r Study However, it was decided that additiona l confirmatory evidence need s to be coUected before these items are incorpo rated in the o ffici al definition of Dysthymic Disorder.
low self-esteem or self-confidence, or feeli ngs of inadequacy feelings of pessimism, despair, or hopelessness generalized loss of interest or pleasure social withdrawal chronic fatigue or ti red ness fe elings of guilt, brood ing about t he past subjective feelings of irritabi lity or excessive anger decreased activity, effectiveness, or productivity d ifficulty in thinking, reflected by poor concentration, poor memory, or indecisiveness
1776
Differential Diagnosis
Appendix B
In DSM-IV, individuals whose presentation meets these research criteria wouJd belliagnosed as having Adjustment Disorder With Depressed Mood if the depressive symptoms occur in response to a psychosocial stressor; otherwise, the appropriate diagnosis is Depressive Disorder Not Othenvise Specified. An episode of minor depressive disorder is distinguished from a Major Depressive Episode by the required number of symptoms (two to four symptoms for minor depressive disorder and at least fi ve symptoms for a Major Depressive Episode). This proposed disorder is considered to be a residual category and is not to be used if there is a history of a Major Depressive Episode, Manic Episode, M ixed Episode, or Hypomanic Ep isode, o r if the presentation meets criteria for Dysthymic or Cyclothymic Disorder. Symptoms meeting research criteria for minor d epressive disorder can be difficult to distinguish from period s of sadness that are an inherent part o f everyday life. lllis proposed d isorder requires that the depressive symptoms be presen t for most of the day nearly every day for at least 2 weeks. In addition, the depressive symptoms must causeclinicaUy significant distress or impairment. Depressive symptoms occurring in response to the loss of a loved one are considered Bereavement (unless they meet the criteria (or a Major Depressive Episode; see p. 349). SubstanceInduced Mood Disorder is distinguished from this disturbance in that the depressive sym ptoms are due to the direct physiological effects o f a d rug of abuse (e.g., alcohol or cocaine) or the side effects of a medication (e.g., steroids) (see p. 405). Mood Disorder Due to a General Medical Condition is distinguished from this disturbance in that the depressive symptoms are due to the direct physiological effects of a general medical condition (e.g., hypothyroidism) (see p. 401). Because d epressive symptoms are common associated features of psychotic disorders, they do not receive a separate diagnosiS if they occur exclusively during Schizophrenia, Schizophrenifonn Disorder, Schizoaffective Disorder, Delusional Disorder, or Psychotic Disorder Not Othenvise Specified. The relationship between this proposed disorder and several other proposed categories included in this appendix (i.e., recurrent brief depressive disorder, d epressive persona lity d isord er, and mixed anxiety-depressive disorder) and with other Personality Disorders is not known, but substantial overlap m ay exist among them.
(a) depressed mood most of t he day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observat ion made by others (e.g ., appears tearfu l). Note: In children and adolescents, can be irritable mood. (b) markedly dim inished interest or pleasure i n all, o r almost all, activities most of the day, nea rl y every day (as indicated by either subjective account or observat ion made by ot hers) (el sig nifica nt weight loss w hen not dieting or weig ht gain (e. g., a change of more than 5% of body weig ht in a month), or decrease or increase in appetite nearly every day. Note : In children, consider fai lure to make expected weight gains. (d) insom nia or hypersomnia nearly every day (e) psychomotor agit at ion or ret ardation nea rl y every day (observable by others, not merely subjective feelings of r estlessness or being slowed down) (f) fatigue or loss of energy nearly every day (g) feelings of worthl essness or excessive or inappropria te guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (h) diminished ability to think or concentrate, or indecisiveness, nearly every day (eit her by subjective account or as observed by others) (i) recu rrent t houg hts of death (not j ust fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specif ic plan for committing suicide (2) the symptoms cause clin ica lly sign ifican t distress or impairment in socia l, occupational, o r other importa nt areas of functioni ng (3) the symptoms are not due to the direct physiologica l effects of a substance (e.g . a drug of abuse, a medication) or a general medical condition (e.g., hypothyroi dism) (4) t he symptoms are not better account ed for by Bereavement (i.e . a norma l reaction to t he death of a loved one) B. There has never been a Major Depressive Episode (see p. 356), and criteri a are not met for Dysthymic Disorder.
C. There has never bee n a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or
a Hypomanic Episode (see p. 368). and criteria are not met for Cyclothymic Disorder. Note: This exclusion does not apply if all of the manic-, mixed-, or hypomanic-like episodes are substa nce or t reatment induced. D. The mood dist urbance does not occur exclusively during Schizophrenia, Schizoph reniform Disorder. Schizoaffective Disorder, Delusiona l Disorder, or Psychotic Disorde r Not Otherwise Specifi ed .
1 778
Recurrent Brief Depressive Disorder
Appe nd ix B
Features
The essential fea ture is the recurrence of brief episodes of depressive symptoms that are identical to Major Depressive Episodes in the number and severity of symptoms but that do n ot meet the 2-week dura tion requirement. See the text for a Major Dep ressi\'e Ep isod e (p. 3-1:9) for a more detailed description o f the characteristic symptoms. The episodes last at least 2 days but less than 2 weeks and most typically have a d ura tion of betw een 2 and 4 days. Episodes must recur at least once a m onth for a period of 12 consecutive months, and they must not be associated exclusively w ith the menstrual cycle. The brief depressive episodes mus t cause clinically significant d istress or impairment in social, occupational, or other important a reas of fun ctioning. In some individuals, there may be near-normal functioning, but this is accomplished with signifi cantly increased effort. A n umber o f d isorders exclud e consideration of this p roposed d isorder. There has never been a Major Depressive, Manic, tvlixed, or Hyp omanic Episod e, and criteria are not met for Dysthymic or Cyclothymic Disorder. The m ood disturbance d oes nol occur exclusively during Schizoph renia, Sch izoph renifo rm Disorder, Schizoaffective Disord er, Delusional Disord er, or Psych otic Disorder Not O therw ise Specified .
Associated Features
The pattern of lifetime or current comorbidity appea rs to be simil ar to that o f Major Depressive Disorder. Associated disord ers may include Substance-Related Disorders and Anxiety Disord ers. The episodes may follow a seasonal p attern. The I -year pre\'alence of this p roposed d isorder has been reported to be about 7% (a ltho ugh this was often in association w ith other established mental d isorders). Males and fem ales appear equally likely to experience recu rrent brief depressive episodes, and the most typical age at onset appears to be in ad olescence. Suicid e attemp ts are the m ost serious comp lication. The rate of depressive disorders is increased in the fi rst-degree biological relatives of individ u als who have recurrent brief depressive ep isod es.
779
p. 405). Mood Disorder Due to a Gen eral Medical Co ndition is dis tingui shed from this dis turban ce in that the depressive sym p toms are due to the direct physiolog ical effects of a genera l medical condition (e.g., hypothyroidis m) (see p. 401). Because depressive symptoms are common associated features of psychotic disorders, they do not receive a separate diagnOSis if they occur exclusively during Schizophreni a, Schizophreniform Disorder, Schizoaffective Disorder, Delusiona l Diso rder, or Psychoti c Disorder No t O th envise Specifi ed. Recurrent brief d epressive disorder shares some clinica l features with Borderline Personality Disorder (i.e., both d isorders manifes t brief and episodic d epressive symptoms such as s uicidal ideation or sadness). In cases where a Personality Disorder and this proposed disorder are both prescnt, both may be noted (with recurren t brief depreSSive disorder noted as Depressive Disorder Not Otherwise Specified). The relations hip between this proposed disorder and several other proposed ca tegories included in this appendix (i.e., minor depressive disorder, depressive personality disorder, and mixed anxiety-depressive disorder) and with o ther Personality Disorders is not known, but s ubs tantial overlap may exis t among them.
C. The depressive periods occur at least once a month for 12 consecutive months and are not associated with t he menstrua l cycle.
D. The periods of depressed mood cause clinically significant distress or impairment in social. occupational, or other important areas of functioning. E. The sympt oms are not due to the di rect physiologica l effects of a substance (e.g . a drug of abuse. a medication) or a general medica l condition (e.g . hypothyroidism). F. There has never been a Major Depressive Episode (see p. 356), and criteria are not met for Dysthymic Disorder. G. There has never been a Manic Episode (see p. 362). a Mixed Episode (see p. 365). or a Hypomanic Episode (see p. 36B), and criteria are not met for Cyclothymic Disorder. Note: This exclusion does not apply if all of the manic-, mixed, or hypo' manic-like episodes are substance or treatment induced. H. The mood disturbance does not occur exclusively during Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusiona l Disorder, or Psychotic Dis order Not Otherwise Specif ied .
Appendi x B
781
distress or impairment in social, occupational, or other importa nt a reas of functioning. The relationship beh\'een this proposed disorder and several othe r proposed categories included in tillS appendix (i.e., minor depressive d isorder, recu rrent brief depressive disorder, and depressive personality disorder) and with o ther Personality Disorders is not known, bu t subs tantia l overlap may exist among them.
D. The symptoms a re not due to the direct physiologica l effects of a substance (e.g . a drug of abuse, a medication) or a general medical condition. E. All of the following: (1) criteria have never been met for Major Depressive Disorder, Dysthymic Disorder, Panic Disorder, or Generalized Anxiety Disorder (2) criteria are not curre ntly met for any other Anxiety or Mood Disorder (including an Anxiety or Mood Disorder. In Partial Remission) (3) the symptoms are not better accounted for by any other menta l disorder
782
Appendix B
gain, are absent. The behavior is not better accounted for by another mental disorder.
The perpetrator induces Of simulates the illness or disease process in the victim and
then presents the victim for medical care while disclaiming any knowledge about the actual etiology of the problem. The most common induced and simu lated conditions include persistent vom iting or diarrhea, respiratory arrest, as thma, central nervous system dysfunction (e.g., seizures, uncoordination, loss of conscious ness), fever, infection , bleeding.. failure to thrive, hypoglycemia, electrolyte disturbances, and rash. The simulation of mental disorders in the victim is much less frequently reported. The type and severity of signs and symptoms are limited only by the medical sophistication and opportunities of the perpetrator. Cases are often characterized by an atypical clinical cou rse in the victim and inconsisten t laboratory test results that are at variance with the seeming health of the victim. The victim is usually a preschool dlild, although newborns, adolescents, and adults may be used as victims. With older dlildren, consideration should be given to the possibility of collaboration with the perpetrator in the production of signs an d symptoms. The perpetTator receives a diagnosis of fa ctitious disorder by proxy. For the victim, Physical Abuse of Child (995.54) or Physical Abuse of Adult (995.81) may be noted if appropriate. In the event of volunta ry collaboration, an additional diagnosis of Factitiolls Disorder may be appropria te for the collaborator.
Associat ed Features
Life stressors, sllch as chronic family d ysfunction, may be present. Perpetrators may exhibit pathological lying (or pseudologia fanta stica) in describing everyday experiences and when presenting the victim fo r medical care. They commonly ha ve considerable experience in health-related areas and seem to thrive in a medical environment. They are often unresponsive to their children when they are lUlaware of being observed. Victims may suffer a significant morbidity and mortality rate as a consequence of the induced conditions or associated problems, such as iatrogenic complications from medications, diagnostic tests, and surgical p rocedures. As they mature, they are at increased risk of d eveloping Factitious Disorder themselves or of emotional and behavioral problems that may include difficu lties in attention and concentration, impaired school perfornlance, or symptoms of Posttraumatic Stress Disorder. The perpetrator is usually the mother, and the father usually appears uninvolved. Sometimes, however, the father or husband may collaborate w ith the mother or may act alone. The perpetrator may a lso be another caregiver (e.g., a baby-sitter, grandmother, or stepmother). Perpetrators may have a history of hav ing been abused. Somatofonn Disorders and Personality Disorders may be present. This proposed disorder often coexists with Factitious Disorder, w hich is usually quiescent as long as the perpetra tor can induce or simulate a factiti ous illness in the \ictim . When confronted with the consequences of their behavior, perpetrators may become d epressed and suicidal. Some become angry with the health care providers, deny the accusations, attempt to remove the victim from the h ospita l against medical advice, and seek care from other providers even at a considerable distance. Perpetrators may fac e criminal charges ranging from abuse to murder. Typically the perpetrator focuses on only one victim at a time, although other Siblings or individuals may have been or might become victims.
783
Differential Diagnosis
In DSM-IV, an individ ual (Le., the perpetrator) whose presen tation meets these re-
sea rch criteria wou ld be diagnosed as having Factitious Di sord er Not Othen.. ise Specified. Factitious disorder by proxy must be distinguished from a general medical condition or a mental disorder in the individual being brought for treatment. Factilious disorder by proxy must also be distinguished from phys ical or sexual abuse that is not motivated by the goal of indirectly assuming the sick role. Malingering differs from facti tious disorder by proxy in that the motivation for the symptom production in Mali ngering is an external incentive, whereas in Factitious Disorder external incentives are absent. Individua ls with Malingering may seek hospitalization for an individual under their care by producing symptoms in an attempt to obtain compensation.
Appe nd ix B
complex (e.g., convulsive movements, falling, running). In possession trance, there is the appearance of one (or several) distinct alternate identities with characteristic behaviors, memories, and attitudes, and the activities performed by the person tend to be more complex (e.g., coherent conversations, characteristic gestures, facial expressions, and specific verbalizations that are culturally established as belonging to a particular possessing agent). Full or partial amnesia is more regularly reported after an episode of possession trance than after an episode of trance (although reports of amnesia after trance are not uncommon). Many individuals w ith this proposed disorder exhibit features of only one type of trance, but some present with mixed symptomatology or fluctuate beh\'een types of trance over time according to local cultural parameters.
Differential Diagnosis
In DSM-lV, individuals wh ose presen tation meets these resea rch criteria would be diagnosed as having Di ssociative Disorder Not Othen vise Specifi ed. This diagnosis should not be made if the trance state is judged to be due to the direct physiological effects of a general medical condition (in which case the diagnosis would be Me ntal D iso rd er Not O then vise Specifi ed Due to a General Medical Conditi on, see p. 190) or a substance (in which case th e d iagnosis would be Substance-Related Diso rder No t O then vise Speci fied ). The symptoms of the trance state (e.g., hearing or seeing spiritual beings and being controlled or influenced by others) may be confused with the ha ll ucinations and delu sions of Schizoph renia, Mood Disorder With Psychotic Features, or Brief Psychoti( Di sord er. The trance stale may be distinguished by its cultural congnlency, its briefet duration, and the absence of the characteristic symptoms of these other disorders. lndi vidu als with Di ssociative Identi ty Disord er can be d istinguished from those with trance and possession symptoms by the fact that those with trance and possession symp toms typically describe external spirits or entities that have entered their bodies and taken over.
customary sense of personal identi ty without replacement by an alternate id entity, associated with at least one of the following : (a) narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on enviro nmental stimuli (b) stereotyped behaviors or movements that are experienced as being beyond one's control (2) possessio n trance, a single or episodic a lteration in the state of consciousness characterized by the replace ment of custo mary sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person, as e videnced by one (or more) of the following: (a) stereotyped and culturally determined behaviors o r movements that are experienced as being controlled by the possessing agent (b) full or partial amnesia for the event B. The trance or possession trance state is not a ccepted as a no rmal part of a collective cultural or religiOUS practice.
C. The trance or possession trance state causes cl inically significant distress or impairment in social. occupational, or other important areas of functioning.
D. The trance or possession trance state does not occur exclusively during the course of a Psychotic Disorder (Including Mood Disorder With Psychotic Features and Brief Psychotic Disorder) or Dissociative Identity Disorder and is not due to the direct physiological effects of a substance or a general medical conditio n.
Binge-Eating Disorder
Diagnostic Features
The essential features are recurrent episodes of binge eating associated with subjec tiYe and behavioral indicators of impaired control over, and significant distress about, the binge eating and the absence of the regular use o f inappropriate campen satory behaviors (such as selfinduced vom iting, misuse of laxatives and o ther med ications, fastin g, and excessive exercise) that are characteristic of Bulimia Nervosa. The characteristics of a binge episode are discussed in the text for Bulimia Nervosa (p. 589). Indicators of impaired control include eating very rapidly, eating until feeling uncomfortably full, eating large amounts o f food w hen not hungry, eating alone because of embarrassment o\'er how much one is eating, and feeling disgust, guilt, or
Appe nd ix B depression a fter overea ting. The marked d istress required for the diagnosis includes unpleasant feelings during and after the binge episodes, as well as concerns abou t the long-term effect of the recurrent binge episodes on bod y weigh t and shape. Binge episodes must occur, on average. at least 2 days a week for a period of at least 6 months. The duration o f a bin ge-eating episode can vary greatly, and many indiv idua ls have d ifficulty separating binge eating in to d iscrete episodes. However, they u sually have li ttle difficulty recalling wh ether or not b inge eating occurred on a given d ay. Thus, it is suggested that the number of d ays on w hich binge eating occu rs be counted , rather than the number of episod es of binge eating, as is done in making the diagnosis of Bulimia Nervosa. Future research sh ould address th is issue. The sym ptom s do not occur exclusively during Anorexia Nervosa or Bulimia Nervosa. In addition, although some inappropriate compensatory behavior (e.g., purging, fasting, o r excessive exercise) may occur occasionally, it is not regularly employed to counteract the effects of the binge eating. Research stud ies conducted to date have varied in how they have defined " regular use of inappropriate compensa tory behaviors." Some studies have equaled "regular" with the hvice-a-week freq uency criterion of Bulimia Nervosa and have consid ered individuals who engage in these behaviors less than twice a week (but as often as once a week) 10 be eligible for the diagnosis o f binge-ea ting disorder. Other studies have excluded ind ividuals who describe any useof inappropriate compensatory beh aviors during the episode of illn ess. Future research shou ld address this issue.
787
typically is in late adolescence or in the early 20s, often coming soon after significant weight loss from dieting. Among individua ls presenting for treatment, the course appears to be chronic.
Differential Diagnosis
In DSM-IV, individuals whose presen tation meets these research criteria would be diagnosed as having Eating Disorder No t Othen..,ise Specified. In contras t to Bulimia N ervosa, in wh ich inappropriate compensa tory mechanisms are employed to counteract the effects of the binges, in binge-eating disorder no such behavior is regularly employed to compensate for the binge eating. Overeating is frequently seen during episodes of Major Depressive Disorder bu t usuaUy does not involve binge eating . TI,is appendix diagnosis should be considered onl y when the individual reports that, during episodes of overeating, both the s ubjective sense of impaired control and three of the associated symptoms lis ted in Criterion B are present. Many individuals are dis tressed by episodes of overeating that are not binge-ea ting episodes.
Note: The method of determining frequency differs from that used for Bulimia Nervosa; future research should address whether the preferred method of setting a frequency th reshol d is counting the number of days on which binges occur or count ing t he number of episodes of binge eating. E. The binge eating is not associated with the regular use of inappropriate compensa tory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during th e cou rse of Anorexia Nervosa or Bulimia Nervosa .
788
App endix B
Features
The essential feature is a pervasive pattern of depressive cogni tions and behaviors that begins by carly adulthood and that occurs in a variety of con texts. lltis pattern does no t occur exclusively d uring Major Depressive Episodes and is not better accoun ted for by Dysthymic Disorder. The depressive cognitions and behaviors include a persistent and pervasive feeling of dejection, gloominess, cheerlessness, joylessness, and unhappiness. These individuals are overly serio us, inca pable of enjoyment or relaxation, and lack a sense of humor. They may feel that th ey d o no t desen 'c to have fun o r 10 be happy. They also tend to b rood and worry, d welling persis ten tly on their negative and tmhappy though ts. Such individuals view the future as nega tively as they view the present; they d oub t that things will ever improve, an ticipate the worst, and while p riding themselves on being realistic, are consid ered by others to be pessimistic. They may be harsh in selfjudgment and p rone to feeling excessively guilty for shortcomings and failings. Selfesteem is low and particularly focused on fee lings of inadequacy. Individuals with this proposed d isorder tend to judge others as harshly as they judge themselves. They often focus on others' failings rather than their posi tive a ttributes, and they may be negativ istic, critical, and judgmental toward others.
Associate d Features
These individuals may be quiet, introverted, passive, and unasserti ve, preferring to foll ow others rather than taking the lead . This pa ttern may occur with approxima tely equ al freq uency in females and males. Individuals with this p resentation may be pred isposed to d eveloping Dysthymic Disorder and possibly Major Depressive Disor der. These conditions may exist on a spectrum, with d epressive personality disorder being the earlyonset, persistent, traitlike varian t of the Depressive Disorders . Preli minary evid ence suggests that depressive personality d isord er may have an increased prevalence in fa mily members of p robands with Major Depressive Disorder. Con versely, Major Depressive Disorder may occur with increased frequency in family members of probands w ith d epressive personality disorder who do not themselves have Major Depressive Disorder.
789
piness, pessimism, self-cri ticis m, and proneness to guilt) in tha t the patte rn is pe rvasive and causes marked dis tress or impairment in social or occupational functi oning . The rela tionship between this proposed di sorder a nd se veral other proposed categories included in this a ppendix (i.e., minor d epressive dis order, recurrent brief depressive disorder, mixed anxie ty-depressive di sord er, and Dysthym ic Disorder when the alternative criteria set also provided w ithin this appendix is used) and w ith other Personality Disorders is not know n, but subs tantial overlap may exist among them .
hood and present in a variety of contexts, as indicated by five (or more) of the fo llowing:
(1 )
usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness self-concept centers around beliefs of inadequacy, worthlessness, and low selfesteem is critical, blaming, and derogatory toward self is brooding and given to worry is negat ivist ic, critical, and judgment al toward others is pessimist ic is prone to feeling guilty or remorseful
B. Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder.
790
Appe ndi x B
unappreciated, and mis understood and chronically complain to o thers. 'Nhen difficulties appear, they blame their failures on the behaviors of others. They may be sullen, irritable,_ impatient, argumentative, cynical, skeptical, and contrary . Authority c fi gures (e.g., a superior at w ork, a teacher at schooL a parent, or a spouse who acts the role of a parent) often become the focus of discontent. Because of their negativism and tendency to externalize blame, these individuals often critici ze and voice hostility toward autho ri ty fi gures with minimal provocation. They are also envious and resentful of peers who succeed or w ho are viewed positively by authority figures. 11,ese indi viduals often complain about their personal misfortun es. They have a negative view of the future and may make comments such as, " It doesn 't pay to be good " and "Good things don't last." These individuals may waver between expressing h ostile defiance toward those they view as causing their problems and attempting to mOllify these persons by asking forgiveness or promising to perform better in the future .
Associated Features
These individuals a re often overtly ambivalent, wavering indecisively from one course of action to its opposite. They may follo w an erratic path that causes endJess wrangles with others and disappointments for themselves. An intense conflict be-h \'een dependence on others and the desire for self-assertion is characteristic of these individuals. Their self-confidence is often poor des pi te a superfi cial bravado. They foresee the worst possible outcome for most situations, even those that are going weU. This defeatist outlook can evoke hostile and negative responses from o thers who are subjected to the complaints of these individual s. This pattern of beh avior often occurs in individuals with Borderline, Histrionic, Paranoid, Dep end en t, Antisocial , and Avoidant Personality Disorders.
Differential Diagnosis
In DSrvl-T individuals whose presentation meets these research criteria would be diV, agnosed as having Personality Disorder Not Othenvise Specified. In Oppositional Defiant Disorder, there is a similar pattern of negativistic attitudes and problems wi th authority fi gures, but Oppositional Defiant Disorder is usually diagnosed in children, whereas this p roposed diso rder should be considered only in adults. This pattern should not be considered if the symptoms are better accOllnted for by Dysthy mic Disorder or if they occur exclusi\rely during Major Depressive Episodes. Passive-aggressive behaviors are frequently encountered in everyday life, particularly among those in authoritarian situations (e.g., work, military, prison) that do not tolerate o ther forms of assertiveness. Only when these passive-aggressive personality traits are inflexible, maladaptive, and cause significant functional impairment or subjective distress do they constitute a disorder.
791
adequate performance, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the fo llowing:
(1) passively resists fu lfilling routine social and occupational ta sks
complains of being misunderstood and unappreciated by others is sullen and argumentative unreasonably criticizes and scorns authority expresses envy and resentment toward those apparent ly more fortunate voices exaggerated and persistent complaints of personal misfortune alternates between hostile defiance and contrition
B. Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder.
A consideration of Medication-Induced Movement Disorders is important in the management by medication of mental dis orders or general medical conditions and in the differential diagnosis with Axis I disorders (e.g., Anxiety Disorder versus Neuroleptic-Induced Aka thisia; catatonia versus euroleptic Malignant Syndrome). These conditions can lead to noncompliance with treahnent and psychosocial and occupational impairments. '[edication-Induced Movement Disorders should be coded on Axis 1. Although these disorders are labeled "medication induced ," it is often difficult to establish the causal relationship between medication exposure and the development of the movement disorder, especially because some of these conditions also occur in the absence of medication exposure. Criteria and text a re provided for these disorders to facilitate research and to e ncourage appropriate diagnos is and treatment. The following Medication-Induced t..,tovement Disorders are included in this section: Neuroleptic-Induced Parkinsonism, Neuroleptic Malignant Syndrome, Neuroleptic-Induced Acute Dystonia, Neuroleptic-Induced Acute Akath.isia, Neuroleptic-Induced Tardive Dyskinesia, and Medication-Induced Postural Tremor. A category for Medication-Induced Movement Disorder T Otherwise Specified is ot also provided for medication-induced movement disorders that do not meet the criteria for any of the specific disorders listed above. These include movement disorders (e.g., parkinsoni sm, acute akathisia) that are associa ted with a medica tion other than a neuroleptic (e.g ., a serotonin reuptake inhibitor). The term l1euroleptic is used broadly in this manual to refer to medications with dopamine-antagonist properties. Although this term is becoming outdated because it highlights the propensity of antipsychotic medications to cause abnormal movements, the term neuroleptic remains appropriate. vVhile newer antipsychotic medi-
792
A ppendix B
syndromes sti ll occur. Neuroleptic medications include so-called conventiona l or typical antipsychotic agents (e.g., chlorpromazine, haloperidol, fluphenazine), the newer "atypical" antipsychotic agents (e.g., clozapine, risperidone, oianzapine, quetiapine), certain dopam ine receptor blocking d rugs used in the treatment of physical symptoms such as nausea (e.g., prochlorperazine, prometha zine, trimethobenzamide, metoclopramide), and amoxapine, which is mar keted as an antidepressan t.
332.1
Neuroleptic-Induced Parkinsonism
Diagnost ic Features
The essential feature of Neuroleptic-Induced Parkinsonism is the presence of parkinsonian signs or symptoms (Le., tremor, muscular rigidity, or akinesia) that develop in association with the use of neuroleptic med ica tion. These symptoms usually develop within a few weeks of starting o r raising the d ose of a neuroleptic med ication or after reducing a medication (e.g., an anticholinergic medication) that is being used to treat or prevent acute extrapyramidal symptoms. The symptoms must not be better accounted for by a mental disord er (e.g., catatonia, negative symptoms of Schizophrenia, psychomotor retardation in a Major Depressive Episode) and are not due to a neurological or other general medical condition (e.g., idiopathic Pa rkinson's disease, \<\' ilson's disease). Rigidity and akinesia are most frequent, w hereas tremor is somewhat less common. It has been estimated that at least 50% of outpatients receiving long-term neuroleptic trea tment with the old er, conventional antipsychotic medications develop some parkinsonian signs o r symptoms at some point in their course of treatment. Rates of Neuroleptic-Ind uced Parkinsonism caused by the newer aty pical antipsychotic medications are considerably lower. Symptoms may develop rapidly after starting o r raising the dose of neuroleptic medication or may develop insidiously over time. The most ty pical cou rse is the d evelopmen t of sympto ms 2--4 weeks after slarting a neuroleptic m ed ication. The symptoms then tend to continue unchanged or to d iminish gradually over the next few months. Sy mp toms w ill usually abate with a reduction of the dose (or discontinuation) of the neuroleptic medication, the addition of antiparkinsonian medication, or a sw itch to a neuroleptic medication with a lower incidence of these side effects. Parkinsolliall tremor is a steady, rhythmic oscillatory movement (3-6 cycles per second) that is typically slower tha n other tremors and is apparent at rest. It may occur intennittently and be unilateral or biJateral or d epend on where the limb is located (positional tremor). The tremor may affect limbs, head, jaw, mouth, lip ("rabbit synd rome"), or tongue. The tremo r can be suppressed, especially when the individual attempts to perform a task with the tremulous limb. Individuals may describe the tremor as "shaking" and report that it occurs especially during times of anxiety, stress, or fatigue. Parkinsonian muscular rigidity is defined as excessive firmness and tensing of resting muscles. It may affect all skeletal muscles or it may only involve discrete mu scular areas. Two kind s of rigid ity occur: cOlltillUOIiS ("lead-pipe") rigidity and cogw/Jee/ rigidity. In lead-pipe rigidity, the limb or joint resists movement and feels locked in
,
Crit eria Sets and Axes Provided for Further Study
793
place. The rigidi ty is con tinuous (i .e., the limb usually does not show moment-tomoment fluctuation s). In cogw heel rigidi ty, as the muscle is stretched arowld a joint there is a rhythmic, ra tchet-like resis tan ce that interrupts the usual smooth motion of the joint. Cogw heel rigidi ty can be felt by p lacing the hand over the joint being moved . Cogwheel rigidi ty occurs when the muscles are passively moved, is mos t common in the w rists and elbows, and often waxes and wanes. Individuals with parkinsonian rigidity may complain of generalized muscle tenderness or s tiffness, muscle or joint pain, body aching, or lack of coordination during sp or ts . Akillesia is a state of decreased spontaneous motor activ ity. There is global slowing as well as slowness in initiating and executing movements. Normal everyday behaviors (e.g., g rooming) are reduced . Individuals may complain of feelin g lis tless, lacking spontaneity and d rive, or oversleeping. Parkin sonian rigidity and akinesia can be manifes ted as abnormalities in gait or d ecreases in length of s tride, arm swing, or overall spontaneity of walking. Other signs include bent-over neck, s tooped shoulders, a staring facial expression, and s mall shuffling steps. Drooling may arise due to a general decrease in pharyngeal motor activity, although it may be less common in parkinsonism associated with neuroleptic medication because of the anticholinergic properties of these medications. Subtle, behavioral manifes tations of akinesia can mimic, or worsen, negative symptoms of Schizopluenia.
Associated Features
Associated behavioral sym p toms may include depression and worsening of negative signs of Schizophrenia. Other associated signs and symptom s include small handwriting (micrographia), hypophonia, postural instability, inhibited blinking in response to glabellae tapping, and seborrhea. General medical complications can occur when parkinsonian symptoms are severe and result in decreased motor activity (e.g., contractures, bedsores, and pulmonary emboli). Decreased gag refl ex and d ysphagia can be life tlueatening and may present as aspiration pneumonia or unexplained weight loss. There may be urinary incontinence and increased rates of h ip fractures in elderly p ersons. Ris k factors for developing N euroleptic-Induced Parkinsonism include a his tory of prior episodes of N euroleptic-Induced Parkinsonism; older age; the presence of a coexisting delirium, dementia, or amnes tic disorder; or a coexis ting neurologica l condition. Children ma y also be a t higher ris k of developing Neuroleptic-Induced Parkinsonis m. Furthermore, the risk of developing Neuroleptic-Induced Parkinsonis m is associated with the type of neuroleptic medication (i.e., older conventional vs. newer atypical antipsychotic medication), the rapidity of increases in dosage, and the absolute dose; the risk is reduced if individuals are taking anticholinergic medications.
Differential Diagnosis
It is important to d is tinguish between Neuroleptic-Induced Parkinsonism and other causes of parkinsonian symptoms in individuals being treated with a neuroleptic medication. Neuroleptic-Induced Parkinsonism should be dis tinguis hed from pa rkinsonian symptoms due to another s ubs tance or medication or due to a neurological or other general med ical condition (e.g., Parkinson 's disease, Wilson's disease).
794
Appendix B
Laboratory findings may h elp to establish other causes for the parkinsonian symptoms (e.g., positive u rine heavy metal screen, basal ganglia calcification indicating hypercalcemia, serum ceruloplasmin indicating Wilson's disease). Tremor due to other causes of parkinsonian symptoms, familial tremor, non-neuroleptic-induced tremor, and tremor associated with Substance Withdrawal should be distinguished from tremor in Neuroleptic-Induced Par kinsonism. Nonparkinsonian tremors tend to be finer (e.g., smaller amplitude) .md faster (lOcyc\es per second) and tend to worsen on intention (e.g ., when the individual reaches out to hold a cup). Tremor associated with Substan ce Withdrawal will usually have associated hyperreflexia and increased autonomic signs. Tremor from cerebell ar disease worsens on intention and may ha\'e associated n ystagmus, ataxia, or scanning speech. Choreifonn movements associated with Neuroleptic-Ind uced Tardive Dyskinesia can resemble parkinsonian tremor; h owever, the parkinsonian tremor is distinguished by its steady rhythmicity. Strokes and other fo cal les ions of the central n ervou s s ystem can cause focal nelUological signs as well as causing immobility from flaccid or spastic paralysis. in con trast, muscle strength is initially nonnal and muscles fatigue later i.n NeurolepticInduced Parkinsonism. Rigidity from parkinsonism also needs to be differentiated from the "clasp knife" phenomenon found in pyramidal lesions and oppositional behavior. Some indications that the parkinsonian symptoms are not due to nelUoieptics include famil y hi story of an inherited neurological condition, rapidly progressive parkinsonism not accounted for by recent psychopharmacological changes, the presence of focal nonextrapyramidal neurological signs (e.g., frontal release signs, cranial nerve abnormalities, or a positive Babinski sign), and parkinsonian signs or symptoms that do not reverse within 3 months of neuroleptic d iscontinua tion (or 1 year when the neuroleptic was given in a long-acting intramuscu lar form). Ind ividuals with Neuroleptic M alignant Syndrome have both severe akinesia and rigid ity but have additional physical and laboratory findings (e.g ., fever, increased creatine phosphokinase [CPK)). Distinguishi ng beh\'een symptoms of a primary mental disorder and behavioral disturbances from Neuroleptic-Induced Parkinsonism can be d ifficult . Often the d iagnosis has to be based on multiple sources o f information (e.g ., physical examination find ings, medication history, mental symptoms). The diagnosis of NeurolepticInduced Parkinsonism may have to be made provisionally and can sometimes only be confirmed by a trial of dosage red uction (or elimination) of the neuroleptic medication or by initiating anticholinergic trea tment. Neuroleptic-induced akinesia and M ajor Dep ressive Disorder ha ve many overlapping symptoms. Major Depressive Disorder is more likel}' to have vegeta tive signs (e.g ., early momi.ng awakening), hopelessness, and despair, whereas apathy is more ty pical of akinesia. Cataton ia associated with Schizophren ia, Ca tatoni c Type, or Mood Disorders With Ca tatonic Features can be particu larly difficult to distinguish from severe akinesia . The n egative sym p tom s of Sch izophreni a may also be difficult to differentiate from akinesia. Rigidity may also be associ ated with Psychotic Disord ers, delirium, d ementia, Anx iety Disord ers, and Con vers ion D isord er. The resistance to passive motion is constant through the full range of motion in parkinsonian rigidity, whereas it is inconsistent in mental disorders or other neurological conditions presenting with rigidity. Furthermore, individuals with parkinsonian rigidity generally have a constel-
795
1,1tion of signs and symptoms, including a characteristic walk and facial expression, drooling, decreased b linking, and other aspects of bradykinesia.
pa rkinsonian t remor (i.e., a coarse, rh ythmic, resting t remor with a frequency between 3 and 6 cycles per second, affecting the limbs, head, mouth, or tongue) (2) pa rk inson ian muscular r igidity (i.e., cogwheel rigidity or continuous "Ieadpipe" r igidity) (3) akinesia (i.e., a decrease in spontaneous facial expressions, gestures, speech, or body movements)
B. The sympt oms in Cri terion A developed within a few weeks of starting or raising the dose of a neu roleptic medication, or of reducing a medication used to treat (or pre' ve nt) acute extrapyramidal symptoms (e .g., anticholinergic agents).
C. The symptoms in Criterion A are not better accounted for by a menta l disorder (e.g .,
catatonic or negative symptoms in Sch izoph renia, psychomotor retardation in a Ma jor Depressive Episode). Evidence that t he symptoms are better accounted for by a menta l disorder might incl ude the following: t he symptoms p recede the exposure to neuroleptic medication or are not compatible with the pattern o f phar macological intervention (e.g ., no improvement after lowering t he neuroleptic dose or administering anticholinergic med ication). D. The symptoms in Cr iterion A are not due to a non neuroleptic substance or to a neu rologica l or other general medical condit ion (e .g., Parkinson's disease, W ilson's disease) . Evidence t hat the symptoms are due to a general medical condition might include the f ollowing : the symptoms precede exposure to neuroleptic medication, unexplained foca l neurological signs are present, or the symptoms progress despite a stable medication regime n.
3 3 3.92
796
Appendix B
and are n ot better acco tmted for by a mental d isorder (e.g., Mood Disorder With Cata
Differential Diagnosis
Neuroleptic Malignant Syndrome must be distinguished from the symptoms of a neurolog ical or other general m edical condition. An elevated temperature that is due to a general medical condition (e.g., a viral infection) must be distinguished from the elevated temperature associated with euroleptic Malignant Syndrome. Extremely elevated temperatures are more likely due to NeuIOleptic Malignant Syndrome, especially in the absence of an identifiable general medical condition. In addition, in Neuroleptic rvlalignant Syndrome, other characteristk features (e.g., severe muscle rigidity) are also present. General medical conditions with a presentation that may resemble NelUoleptic Malignant Syndrome include central nervous system infection, s tatus epilepticus, subcortical brain lesions (e.g., stroke, trauma, neoplasms), and systemic conditions (e.g ., intermittent acute porphyria, tetanus). Heat stroke may mimic Neuroleptic Malignant Syndrome but can be d istinguished by the presence of hot, dry s kin (rather than diaphoresis), hypotension (rather than fluctu ating or elevated blood pressure), and limb flaccidity (rather than rigidity). Malignant h yperthenni a presents with high elevated temperature and rigidity and usually occurs in genetically susceptible individuals who have received halogenated inhalational anesthetics and depolarizing muscle relaxants. Malignant h}'perthermia usually starts within minutes of receiving anesthesia. Because other general medical conditions can co-occur with or result from Neuroleptic Malignant Syndrome, it is important to determine whether the elevated temperature occurred before or subsequent to the superimposed medical problems. Abrupt discontinuation of antiparkinsonian medication in a person with Parkinson' s disease or treatment w ith dopaminedepleting agents (e.g., reserpine, tetrabenazine) may precipitate a reaction similar to Neuroleptic Malignant Syndrome. Neuroleptic Malignant Syndrome must be distinguished from similar syndromes resulting from the use of other psychotropic medications (e.g ., monoamine oxidase inhibitors, monoamine oxidase inhibitor-tricyclic combinations, monoamine oxidase inhibitor-serotonergic agent combinations, monoamine oxidase inhibitor-meperidine combinations, lithilUTI toxicity, anticholinergic delirium, amphetamines, fenflura mine, cocaine, and phencyclidine), all of whidl may present w ith hyperthermia, altered mental status, and autonomic changes. In s uch cases, a diagnosis of MedicationInduced Movemen t Disorder Not Otherwise Specified can be given. Indi viduals with Schizopluenia or a Manic Episode who are not receiving a neuroleptic medication may sometimes present with extreme ca tatonic s tates (so-called leth al catatonia), which can mimic Neuroleptic rv[alignant Syndrome and may in-
798
Append ix B
dude elevated temperature, autonomic dysfun ction, and abnonnal laboratory find ings. For individuals already receiving a neuroleptic med ication, a history of prior extreme catatonic s tales when the individual was n ot receiving a neuroleptic is im p ortant in making the differential diagnosis. The problem is further confounded by the fact that neuroleptic medication may worsen the symptoms of lethal catatonia.
(2) dysphagia
(3) (4) (5) (6) (7) (8) (9) (10)
tremor
incontinence
changes in level of consciousness rang ing from confusion to coma mutism tachycardia elevated or labi le blood pressure leucocytosis laboratory evidence of musde injury (e.g., elevated CPK)
C. The symptoms in Criteria A and B are not due to another substance (e.g., phencyclidine) or a neurologica l or other genera l medical condition (e.g., vi ral encephalitis). D. The symptoms in Criteria A and B are not better accounted for by a mental disorder (e.g., Mood Disorder With Cataton ic Features).
333.7
Diagnostic Features
n le essen tial featlUe of Neurolep tic-Induced Acu te Dystonia is s ustained abnormal postures or muscle spasms that develop in association w ith the use of neuroleptic medication. TIlese include abnormal positioning of the head and neck in rela tion to the body (e.g., retrocoJlis, torticollis); spas ms of the jaw muscles (trismus, gaping, grimacing); impaired swallowing (dysphagia), speaking, or breathing (potentially lifethreatening lar}'flgeal-phary ngeal spasm, d ysphonia); thickened or slurred speech due to hy pertonic tongue (dysarthria, macroglossia); tongue protrusion o r tongue d}'sfunction; eyes deviated up, down, or sideward (oculogyric crisis); or abnormal positioning of the d is tal limbs o r trunk (opisthotonos). nlere is great variability in the severity of the symptoms and in the body areas that may be affected . Increased tonE' in the affected muscles is us ually present. The signs or symptoms develop withi. 7 days of s tarting o r rapidly raising the dose of neuroleptic medication or of reducinl
Criteria Sets and Axes Provided for Further Study a medication being u sed to treat or prevent acute extrapyramidal symptoms (e.g., anticholinergic agents). The symptoms must not be better accounted for by a mental disorder (e.g., catatonic symptoms in Schizophrenia) and must not be due to a nonneuroleptic substance or to a neurological or other general medical condition.
Associated Features
Fear and anxiety often accompany the onset of Nernoleptic-Ind uced Acute Dystonia, especially in individuals w ho are lmaware of the p ossibility of developing dystonia and who mistakenly regard the symptom as part of their mental disorder. Some individuals experience pain or cramps in affected muscles. Noncompliance with medication treatment may result following the development of acute d ystOniC reactions. Neuroleptic-Induced Acute Dystonia occurs most commonly in youn g males. Risk facto rs for developing Neuroleptic-Ind uced Acute Dystonia include prior d ystonic reactions to neuroleptic treatment and the u se of high-potency typical neuroleptic medication. euroleptic-lnduced Acute Dystonia is far less likel y to occur w ith atypical neuroleptic medications (i.e., fewer than 5% of treated individuals).
er causes of d ystonia in individuals being treated with a neurolep tic medication. Evidence that the symptoms are due to a n eu rological or other gen era l medical condition includes course (e.g., symptoms preceding exp osure to the neuroleptic medica tion or progression of symptoms in the absence of change in medica tion) and the presence o f focal neurological signs. Spo ntaneo usly occurri ng foca l or segmenta l dys lonias usually persist for several d al's or weeks independent of medication. Other neurological conditions (e.g., temporal lobe seizures, viral and bacterial infections, trauma, or space-occupy ing lesions in the peripheral or central n ervous system) and endocrinopathies (e.g., hypoparathyroid ism) can also produce symptoms (e.g., tetany) that resemble a N euroleptic-Induced Acute Dystonia. Neuroleptic Malignant Syndrome can produce d ystonia but differs in tha t it is also accompanied by fever and generalized rigidity. Neuroleptic-lnduced Acute Dystonia should be distinguished from dys tonia due to a n onneuroleptic m edication (e.g ., anticonvulsant medications such as phenytoin and carbamazepine). In such cases, a diagnosis of Medicat ion-Induced Movemen t D iso rder Not Othe n vise Specified can be given . Catatonia associated ,..,.jth a Mood Disorder or Schizophreni a can be distinguished by the temporal relationship between the symptoms and the neuroleptic exposure (e.g., d ystonia preceding exposure to neuroleptic medication) and response to pharmacological intervention (e.g., no improvement after lowering of neuroleptic dose or anticholi nergic administration). Furthermore, individuals w ith NeurolepticInduced Acute Dystonia are generaUy distressed about the dystonic reaction and usually seek intervention . In contrast, individ uals with cata tonia are typically mute and withdrawn and do not express subjective distress about their condition.
800
Append ix B
B. The signs or symptoms in Criterion A developed within 7 days of st arting or rapidly raising the dose of neuroleptic medication, or of reducing a med ication used to treat (o r prevent) acute extrapyramida l symptoms (e.g., anticholinergic agents).
C. The symptoms in Criterion A are not better accounted for by a ment al disorder (e.g., catatonic symptoms in Schizophrenia). Evidence that the symptoms are better accounted for by a menta l disorder might include the fo llowing: the symptoms precede t he exposure to neuroleptic medicat ion o r are not compatible with the pattern of pha rmacological intervention (e.g., no imp rovement aher neu roleptic lowering or anticholinergic ad ministration).
O. The symptoms in Criterion A are not due to a nonneuroteptic substance o r to a neu ro logical or other general medical condition. Evidence that t he symptoms a re due to a general medical condition might include the follow ing: the symptoms precede the exposure to the neuro leptic med ication, unexplained focal neurological signs are present, or the symptoms progress in the absence of change in medication .
333.99
Differential Diagnos is
Neuroleptic-Induced Acu te Akathisia may be clinically indistinguishable from syndromes of restlessness due to certain neurological or other general medicaJ conditions, to nonneuroieptic substances, and to agitation p resenting as part of a mental disorder (e.g., a Manic Episode). TIle akathisia of Park inson's disease and iron-deficiency anemia are phenomenologically simila r to Neuroleptic-Induced Acute Akathisia . The frequently abrupt appearance of restlessness soon a ft er initi ation or increase in neuroleptic medication usually distinguishes Neuroleptic-Induced Acute Akathisia. Seroton in-specific reup take inhibitor antidepressant medications may produce akathisia that appears to be identical in phenomenology and treatment response to Neuroleptic-Induced Acute Akathisia. Akathisia due to nonneuroieptic medication can be diagnosed as Medicationlnduced Movement Disorder Not Othenvise Specified. Other situations that might be included under Med ica tion-Induced Movement Disorder Not Otherwise Specified are acute akathisia w ith onJ y subjective or only objective complaints, but not both; and akathisia occurring late in the course of treatment (e.g., 6 months after initiation of, or increase in the dose o f, a neuroleptic). Neuroleptic-Induced Tardive Dyskinesia also often has a component o f generalized restlessness that may coexist w ith akathisia in an individ ual receiving neuroleptic medication. Neuroleptic lnduced Acute Akathisia is differentiated from NeurolepticInduced Tardi ve Dyskinesi a by the nature of the movements and their relationsh ip to the initiation of medication. The tinle course o f symptomatic presentation relative to neuroleptic d ose changes may aid in this distinction. An increase in neuroleptic med-
802
Appe ndix B
icatian will often exacerbate akathisia, whereas it often temporarily relic\'es the symptoms of Tardive Dyskinesia . Neuroleptic-Induced Acute Akathisia should be d istinguished from symptoms tha i are better accounted for by a mental disorder. Individua ls with Dep ressive Episod es, Manic Episod es, Generalized Anxiety Disord er, Schizophrenia an d other Psych otic Disord ers, Atten tion-DeficitfHyperac!ivity D isorder, de mentia, d elirium, Sub s tan ce Intoxication (e.g., with cocaine), or Sub s tance Withdrawal (e.g., from an opioid) may also display agitation that is difficult to d is tinguis h from akathisia. Some of these ind ividuals are able to differentiate akatltis ia from the anxiety, restlessness, and agitation characteristic of a mental disorder by their experience of akathisia as being different from previously experienced feelings . Othe r evidence that restlessness or agitation may be better accounted for by a mental dis order includes the onset of agita tion prior to expos ure to the neuro leptic medication, absence of increasing restlessness w ith increasing neuroleptic medication doses, and absen ce of relief with pharmacological interventions (e.g., no improvemen t after decreasing the neuroleptic d ose or treatment with medica tion intended to treat the akathis ia).
(2) rocking from foot to foot while standing (3) pacing to relieve rest lessness (4) ina bil ity to sit or stand sti ll for at least several minutes
C. The onset of the symptoms in Criteria A and B occurs with in 4 weeks of initiat ing or
increaSi ng the dose of the neuroleptic, or of reducing medication used to treat (or prevent) acute extrapyramidal symptoms (e.g .. anticholinergic agents) . D. The symptoms in Crit erion A are not better accounted for by a mental disorder (e.g., Schizophrenia. Subst ance Withdrawal, agitation from a Major Depressive or Manic Episode. hyperactivity in Attention-Deficit/Hyperactivity Disorder). Evidence that symptoms may be bette r accounted for by a mental disorder might include the fol lowing: the onset of symptoms preceding the exposure to the neuroleptics, the absence of increaSing restlessness with increasing neuroleptic doses, and the absence of relief with pharmacological interventions (e.g., no improvement after decreasi ng the neuroleptic dose or treatment with medication intended to t reat the a kathisia). E. The symptoms in Crit erion A are not due to a non neuroleptic su bstance or to a neu rological or other general medical condition. Evidence that symptoms a re due to a general medical condition might include the onset of the symptoms preceding the exposure t o neu roleptics or the progression of symptoms in the absence of a change in medication.
333.82
Associated Features
The symptoms of Tard ive Dyskinesia tend to be worsened by stimulants, neuroleptic withdrawal, and anticholinergic medica tions and may be transiently worsened by emotional arousal, stress, and distraction during voluntary movements in unaffected parts of the body. The abnormal movements of dyskineSia are transiently reduced by relaxation and by voluntary movements in affected parts of the body. They are generally absent during sleep. Dyskinesia may be suppressed, at least temporaril y, by increased d oses of neuroleptics or sedati ves. The overall p revalence of Neuroleptic-Induced Tardive Dyskinesia in individuals who have received long-term neuroleptic trea tment ranges from 20% to 30%. The overall incidence among younger individ uals ranges from 3% to 5% per year. Middle-age and elderly individuals appear to develop euroleptic-Induced Tardive Dyskinesia more often, with prevalence figures reported up to 50% and an incidence of
804
Append ix B
25%-30% after an average of 1 year's cumulative exposure to neuroleptic medication. Prevalence also varies depending on setting, with Tardive Dyskinesia tending to be
more common among inpatients (especiaUy duonically ins titutionalized individuals). Varia tions in reported prevalence may be due to a lack of consistency in the definition of caseness, neuroleptic prescribing practices, study d esign,. and the demogra ph ics of the population being s tudied. There is no ob\,jous gender difference in the susceptibility to Tardive Dyskinesia, although the ris k may be somewhat greater in posbnenopausai women. Greater cu-
mulative amounts of typical neuroleptics and early development of extrapyramidal side effects are tw o o f the most consistent risk fa ctors for Tardive Dyskinesia. Mood Disorders (especially Major Depressive Disorder), neu rological conditions, and Alcohol Dependence have also been found to be risk factors in some g roups of individuals. There is grow ing e\' idence that the newer atypical neuroleptics are associated with a mudllower incidence of Tardive Dys kinesia than the typical neurolepties. Onset may occur at any age and is almost always insidious. The signs are ty pica U y minima l to mild at onset and escape notice except by a keen observer. In a majority of cases, Tardive Dyskinesia is mild and is p rimarily a cosmetic problem. In severe cases, however, it may be associated. with general m edical complications (e.g., ulcers in cheeks and tongue; loss of teeth; macroglossia; difficulty in walking, swallOWing. or breathing; muffled speech; weight loss; depression; and suicidal ideation). If the individual w ith Tardive Dyskinesia remains off neuroleptic medica tion, the d yskinesia remits within 3 months in one-third of the cases and remits by 12-18 months in more than 50% of cases, although these percentages are lower in old er persons. When individuals receiving neuroleptic medica tion are assessed periodically, Tardive Dyskinesia is fo und to be stable over time in about one-half, to worsen in one-quarter, and to improve in the rest. Younger individuals generally tend to improve more readily; in older indiv idua ls there is a greater likelihood that Ta rdive Dyskinesia may become more severe or more generalized wi th continued neu roleptic use. When neuroleptic medications are discontinued , it is estimated that 5%- 40% of all cases remil and beh veen 50% and 90% of mild cases remit.
805 1
ua l. Neuroleptic-Induced Tardive Dyskinesia must be disting uished from symptoms tha t are due to a neuroleptic-ind uced acute movement disorder (e.g., NeurolepticInd uced Acute D ystoni a or Neu roleptic-Induced Acute Akathi sia). N eurolepticInduced Acute Dystonia d evelops within 7 days and Neuroleptic-Induced Acute Akathisia d evelops within 4 weeks of initiating o r increasing the d ose of a neuro leptic medica tion (or redUCing the dose of a medication used to treat acute extrapyramidal symptoms). Neuroleptic-Induced Tardive Dyskinesia, on the other hand, develops during exposure to (or withd rawal from) neuroleptic medication in individuals with a history of neuroleptic use fo r at least 3 months (or 1 month in middle-age and elderly persons).
333.1
806
Appendix B
which such a tremor may be associated include lith ium, beta-adrenergic medica tions (e.g., isoproterenol), s timulants (e.g., amphetamine), dopamincrgic medications, anticonvulsant medications (e.g., valproic acid), neuroleptic medications, antidepressant medications, and methylxanthines (e.g., caffeine, theophylline). The tremor is a regular, rhythmic oscillation of the limbs (most commonly hands and fing ers), head, mouth, or tongue with a frequency of behveen 8 and 12 cycles per second. It is most easily observed when the affected body part is held in a sus tained pos ture (e.g., hands ou tstretched, mouth held open). ''''hen an individual describes a tremor that is consis ten t with this definition, but the clinician does not directly observe the tremor, it may be helpful to try to r~crea t e the situation in which the tremor occurred (e.g., drinking from a cup and saucer). The symptoms are not due to a preexisting, nonpharmacologically induced tremor and are not better accounted for by leurolepticInduced Parkinsonis m.
Associated Features
Most available information concerns lithium-induced tremor. Li thi um tremor is a common, u sually benign, and well-to lerated side effect of therapeutic doses. However, it may cause social embarrassment, occupational difficulties, and noncomplian ce in some individuals. As senlm lithium levels approach toxic levels, the tremor may become more coarse and be accompanied by muscle twitching, fa scicula tions, or ataxia . Nontoxic lithium tremor may improve spontaneously over time. A variety of factors may increase the ris k of lithium tremor (e.g., increasing age, high serum lithium levels, concurrent antidepressan t or neuroleptic medica tion, excessive caffeine intake, personal or family his tory of tremor, presence o f Alcoh ol Dependence, and associated anxiety). The freque ncy o f complaints about tremor appears to decrease with duration of lithium treatment. Factors that may exacerbate the tremor include anxiety, s tress, fati gue, h}'poglycemia, thyrotoxicosis, pheochromocytoma, hypothermia, and Alcohol Withdrawal.
Differentia l Diagnosis
Medication-Induced Poshlral Tremor should be distinguished from a preexisting tremor that is not ca used by the effects o f a medication. Factors that help to es tablish that the tremor was preexis ting include its temporal relationship to the initiation of medication, lack of correlation with serum levels of the medication, and persistence after the medica tion is discontinued. If a preexisting, nonpharmacologically induced tremor is present that worsens with medication, such a tremor would not be considered to meet the criteria for a Medication-Induced Pos hlral Tremor and would be coded as Medication-Induced Movement Di sorder Not Othenvise Specified. The fa ctors described above that may contribute to the severity of a Medication-Induced Postural Tremor (e.g., anxiety, s tress, fatigue, hypoglycemia, thyrotoxicosis, pheochromocytoma, hypothermia, and Alcohol Withdrawal) may also be a cause of tremor independent of the medication. Medication-Induced Poshlral Tremor is not diagnosed if the tremor is better accounted for by euroleptic-In duced Parkinsonism. A Medication-Induced Poshual Tremor is usually absent at rest and intensifies when the affected part is brought into
Criteria Sets and Axes Provided for Further Study action or held in a sustained position. In contrast, the tremor related to Neuroleptic Induced Pa rkinsonism is usually lower in frequency, worse at rest, and suppressed y during intentional movement and usuaU occurs in association w ith other symptoms of Neuroleptic-Induced Parkinsonism (e.g., akinesia, rigidity) .
333.90
This category is for Medication-Induced Movement Disorders that do not meet criteria for any of the speciIic di sorders listed above. Examples include 1) parkinsonism, acute aka lhisia, acute d ystonia, or d yskinetic movement that is associated with a medication other than a neuroleptic; 2) a presentation that resembles Neuroleptic Malignan t Syndrome that is associated w ith a medication o ther than a neuroleptic; or 3) tardive dystonia.
808
Appendix B
specifi c d efen ses o r coping sty les (starting with the most prominent) and then indi+ cate the predominant defense level exhibited by the individual. These should renect the defenses or coping styles employed at the time of evaluation, supplemented by whatever in fonnation is available abou t the ind ividual 's defenses or coping patterns during the recent time p eriod that preceded the evaluation . TIle specific defense mechanisms lis ted may be drawn from the d ifferent Defense Levels. The Defensive Functioning Axis is presen ted firs t, followed by a recording form. The res t of the section consists of a list of definitions for the specific defense mechani sms and coping styles.
anticipation affilia tion altruism humor self-assertion self-observa tion subl imation suppressIOn
Mental inhibitions (compromise form ation) level. Defensive fun ctioning at this level keeps potentially threatening ideas, fee lings, memories, wishes, or fears out of awa reness. Examples are
d isplacement d issociation in tellectualiza tion isolation of affect reaction formation repressIOn undoing
Minor image-d istorting level. This level is characterized by distortions in the image of the self, body, o r olhers that may be employed to regu late self-esteem. Examples are deva luation idea lization omnipotence
.. .
Level o f d efen sive dysregulati on. This level is characterized by failure of defensive regulation to contain the individ ual's reaction to slressOfs, leading 10 a pronounced break with objective reality. Examples are delusional p rojection psych otic denial psychotic d istortion
810
Appendix B
2.
3.
" ,.
6.
7.
Examp le
Major Depressive Disorder, Recurrent, Moderate Seda tive, H ypnotic, or A nxiolytic Abuse Axis n: Borderline Personal ity Disorder Antisocial personality feahlres Axis ill: 881.02 Lacerations o f wris l Axis IV: Recent arrest ExpulSion from home by parents Axis \1: GAF =45 (currcnt)
296.32 305.40 301.83 Axis J:
812
Appendix B
humor The individual d eals w ith emo tional (onfliet o r external stressors by emphasizing the amusing or ironic aspects of the conflict or stressor.
idealiz ati on The individual d eals w ith emotional con fli ct or internal or external stressOTS by attributing exaggerated pos itive qualities to others. intellectualization The individual d eals w ith emotional conflict or in ternal or external stressors by the excessive use of abs tract thinking or the making o f generalizations to control o r m inimize di sturbing feelings . isol ation o f affecl The indi vidual deals w ith emotional conflict o r internal or external stressors by the separation of ideas from the feelings originally associa ted with them. The individual loses touch w ith the feelings associated with a given id ea (e.g., a tra umatic event) w hile remaining aware of the cognitive elements of it (e.g., descriptive details).
omnipotence The ind iv idua l deals w ith emotional conflict or in ternal or external s tressors by feel ing or ac ting as if he or she possesses s pecial powers or abilities and is s uperior to o thers. p assive aggression The indi vidual d eals w ith emotional conflict or internal or externa l s tressors by indirectly and unassertively exp ressing aggression toward o thers. There is a facade of overt compliance mas king covert resis tance, resentmen t, or hostility. Passive aggression often occu rs in response to demands for ind ependent action or performance or the lack of gratific ation of dependent wishes b ut may be ad ap tive for individuals in s ubord inate positions who have no olher w a)' to express assertiveness more O\'erl l),. p rojecti on The individual d ea ls w ith emotional conilict or internal or external stressors by fa lsely attributing to another h is or her own unaccepta ble feelings, impulses, or thoughts. p ro jective iden tification As in p rojection, the individual d eals with emotional conflict or internal or external stressors by falsely attributing to another h is or her own unacceptable fee lings, impulses, or thoughts. Unlike simple p rojection, the individual does not full y d isavow w hat is projected. Ins lead , th e ind ividual remains awareof his or her ow n affects or impulses but mis a ttribu tes them as justifiable reactions to the other person . Not in frequently, the indi vidual induces the very feel ings in others that were firs t mistaken ly believed to be there, making it diffic ult to clarify w ho d id what to whom firs t. rational ization The individual deals w ith emotional conflict or internal or external stressors by concealing the true motivations fo r his or her own thoughts, actions, or feel ings through the elaboration of reassuring or self-serving bu t incorrect explanations. reaction formati on The individ ual d eals with emotional conflict or internal or external stressors by s ubs tituting behavio r, thoughts, or feelin gs that are diametrically
813 1
opposed to his or her own unacceptable UlOughts or feelings (tiUs u sually occurs in conjunction with their repression). re pression The ind ividual deals with emotional conflict or internal or external stressors by expelling disturbing wishes, thoughts, or experiences from conscious awareness. The fee ling component may remain conscious, detached from its associated ideas. self-asse rtion The individual deals w ith emotional conflict or stressors b y expressing his or her feelings and thoughts directly in a way that is not coercive or manipula tive. self-observation The individ ual deals w ith emotiona l conflict or stressors by reflecting on his or her own thoughts, feelings, m otiva tion, and behavio r, and responding appropriately. splitting The individual deals with emotional conflict or internal or external stressors by compartmentalizing opposite affect states and failing to integrate the p ositive and negative qualities of the self or others into cohesive images. Because ambivalen t affec ts cannot be experienced simultaneously, more balanced. views and expectations of self or o thers are excluded from emotional awareness. Self and object images tend to alternate between polar opposites: exclusively loving, powerfu l, worthy, nurturan!, and kind-or exclusively bad, hateful, angry, destructive, rejecting, or worthless. sub limati on The individual deals with emotional con fli ct or in ternal or external stressors by channeling potentially maladaptive feelings o r impulses into socially acceptable behavior (e.g., contact sports to channel angry impulses). suppressi on The individua l deals with emotional conflict or internal or external stressors b)' intentionally avoid ing thinking about disturbing problems, w ishes, feel. . mgs, or expcnences. undoing The individual deals w ith emotional conflict or internal or external stressors by words or behavior d esigned to negate or to make amends symbolically for unacceptable thoughts, feelings, or actions.
Appendix B
Overall: RelatjO Imit is fimctioning satisfactorily from self-report of particillal pal/ts and from perspectives of obseroers. Agreed-on patterns or routines exist that help meet the usual needs of each famil y / couple member; there is flexibility for change in response to unusua l demand s or events; and occasional conilicts and stressful transitions are resolved through problem-solving communication and negotia tion. There is a shared understand ing and agreement abou t roles and appropriate tasks, decision making is established for each functional area, and there is recognition of the unique characteristics and merit of each subsystem (e.g., parents / spouses, siblings, and individ uals). There is a situationaUy appropriate, optimistic atmosphere in the family; a wide range o f feelings is freely expressed and managed w ithin the family; and there is a general ahnosphere of warmth, caring, and sharing of values among all family members. Sexual relations of aduJ t members are sa tisfactory.
81-100
Overfill: FlIlICliollilig of relatiollalullit is sOIllf!1vlltl! IfIlSfitisfactory. Oller a period of time, mallY bllt 1I0t all diffiClllties are" resolved without colllplaillts. Dail y routines are present, but there is some pa in and d ifficulty in responding to the unusual. Some conflicts remain unresolved but do no t disrupt family functioning. Decision making is usu ally competent, but efforts at control o f one another quite often are grea ter than necessary or are ineffective. Individuals and relationships are d early demarcated but sometimes a sp ecific subsystem is d epreciated or scapegoated. A range of feeling is expressed, but instances of emotional blocking or tension are evident. Warmth and caring are present b ut are m arred by a famil y member's irritability and frustrations. Sexual activity of adult members may be reduced or problematic. Overall: RelatiOllal ,m it Iltls occasiollal fimes of satisfying and competent f llIlCliolling logct/ler, bill clearly dysful/ ctional, Ill/satisfying relationships fwd to predominate. Communication is frequ entl y inhibited by lUllesolved confl icts that o ft en interfere w ith daily routines; there is Significant difficulty in adapting to famil y stress and transitional change. Decision making is only intennittently competent and effective; either excessive rigidity or significant lack of structure is eviden t at these times. Individual needs are quite often submerged by a p artner or coa lition. Pain o r ineffective anger or emotiona l deadness interferes with family enjoyment. Although there is some warmth and support for members, it is usually unequaUy d istributed. Troublesome sexual diffiClllties between adults are o ften present.
41-60
Overfill: Refa fioll fll ullit is obviously alld seriously dysfimctiollal; forms and tillle periods of satisfactory relflting are rare. Famil)' / couple routines d o not meet the need s of members; they are grim ly adhered to or blithely ignored . Life cycle changes, such as d ep artures or en tries into the relation al unit, generate painful conflict and ob viously fru strating fa ilures of problem solving. Decision ma king is ty rannica l or quite ineffective. The unique characteristics of ind ividuals are unappreciated or ignored by either rigid or con fu singly fluid coalitions. There are infrequen t period s of enjoyment of life together; frequent distancing or open hostility reflect significant conflicts that remain unresolved and quite painful. Sexual d ysfunction among adult m embers is conunonplace.
21-40 1-20
Overall: Reial;Olla/ullit Iltls become too dysfimctiollal lo retaill COlltillllity of CO I/tflcl and aUac1/11ICIlI. Family / couple routmes arc negligible (e.g., no mealtime, sleep ing, or waking schedu.le); family members often do not know where others arc or when they will be in or out; there is a little effective communication among famil y members. Fa mily/ couple members are not organized in su ch a way that personal or generational res ponsibilities arc recog nized. Bou ndaries o f relational unit as a
816
Appendix B
whole and subsystems cannot be identified or agreed on. Family members are physicall}, endangered or injured o r sexually attacked. Despair and cynicism are pervasive; there is little attention to the emotional needs of others; there is almost no sense of attachmen t, commitment, or concem about one another's welfare. o Inadequate information.
817
Appendix B
I
91
90
I
81
80
I
71
No more than a slight impairment in social. occu pational, or school functioning (e.g., in frequent interpersonal conflict, temporarily falling behind in schoolwork).
70 Some d ifficulty in soda I. occupational, or school functioning, but generally functioni ng I we ll, has some meaningful inte rpersonal relationships.
61
60 Moderate d ifficulty in social, occupat iona l, or school functioning (e.g., few friends, conI fliet!; with peers or co-wo rk ers).
51
SO
I
41
Serious impairment in social, occupational, or school functioning (e.g., no fri e nds, unable to keep a job).
40 Major impai rme nt in several areas, such as wo rk or school, fami ly re lations (e.g., deI pressed man avoids friends, neglects family, and is una ble to wo rk; child frequently beats 31 up younger childre n, is defian t at home, and is fai ling at school). 30 Inability t o funct ion in al most all areas (e.g., st ays in bed all day; no job, home, or friends).
I
21
20 Occas io nally fa ils t o ma intain minimal personal hyg iene; u nable to function indepenI dently.
11
10 Persistent inabili ty to maintain min imal personal hygie ne . Unable to function witho ut I harming self or others or without consid erable externa l support (e.g., nu rsing care and 1 supervision).
Inadequate information .
Note: The rating of overall psychological functioning on a scale of 0-100 was operati onalized by Luborsky in the Health-Sickness Rating Scale. (Luborsky L: - Clinicians' Judgments of Mental Health.A rchives of General Psychia try 7:407--417, 1962). Spitz er and colleagues developed a revision of the Health-Sickness Rating Scale called the Global Assessment Scale (G AS) (Endicot t J. Spitzer RL, Fleiss JL, et al.: - The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Disturbance. _ Archives of General Psychia try 33:766-77 I, 1976). The SOFAS is d erived from the GAS and its develo p men t is described in Goldman HH, Skodol AE, Lave TR: - Revising Ax is V fo r OSMoN: A Review of Measures o f Social Functio ning. _ American Journal of Psychiatry 149: 1148-11 56, 1992.
Appendix C
affect A pattern of observab le behaviors that is the exp ression of a s ubjectively experienced feeling s tate (emotion). Common examples of affect are sadness, elation, and anger. In contrast to mood, w hich refers to a more pervasive and s us tained emotional "climate," tlffect refers to more flu ctua ting changes in emotional "weather." Wha t is cons idered the normal range of the expression of affect varies considerably, both w ithin an d amon g diffe rent cultures. Disturbances in affect include blunted Sign ifi cant reduction in the intensity of emotional expression.
flat Absence or near absence of any signs of affective expression. inapprop ri ate Di sco rdance between affecti ve expression and the content of
speech or ideation. labil e Abnormal variabili ty in affect with repeated , rapid, and abrupt shifts in affective expression . restricted or constricted Mi ld reduction in the range and intensity o f emotion al expression . agitation (psych omo tor agitation) Excessive m otor acti vity associa ted with a feeling o f inner tens ion . The activity is us ually non p roductive and repetitious and consists of such behavio r as pacing, fi dgeting, w ring ing o f the hands, pullin g o f clothes, and in ability to sit still . agoni st medication A chemical en tity extrinsic to endogenously produced substances that acts on a receptor and is capable of producing the maximal effect that can be prod uced by s tim ulating that receptor. A parti al agoni st is capable o nly of producing less than the ma ximal effect even when g iven in a concentra tion s ufficie nt to bind with all availa ble receptors. agonis t/antagon ist medication A chemical entity extrin s ic to endogenous ly prod uced su bstan ces tha t acts on a family of rece ptors (such as mu, d elta, and kappa opiate rece p tors) in s uch a fa sh ion th at it is an agonis t or partial agonis t on one type of recep tor and an antagon is t on another. Glossary definitions were informed by the foll owing sources: DSM-lll; DSM-Ul-R; America" Psychiatric G/OSstlry, 6th Edi tio n; Penguiu Dictionary of Psychology; Campbell's Psychiatric Die/ioIwry, 6th Edi tio n; Stedmall'S Medical Dictiouary, 19th Editio n; Dorlalld's lIIustrated A'kdica/ Die/ioIWry, 25th Edition; and \'\'ebster's Third Nf!iu lutenlatiol/al Dictiollary.
819
1 820
Appendix C
alogia An impoverishment in thinking that is inferred from observing speech and language behavior. There may be brief and concrete replies to questions and restriction in the amount of spontaneous s peech (poverty of speech ). Sometimes the speech is
adequate in amount but conveys little informa tion because it is Qverconcretc, overabstract, repetitive, or s tereotyped (poverty of content).
amnesia
Loss of memory. Types of amnesia include Loss of memory of events that occur after the onset of the etio-
anterograde
retrograde Loss of memory of events that occurred before the onset of the etiological condition or agent.
antagonist medication A chemical entity extrinsic to endogenously produced substances that occupies a receptor, produces no physiologic effects, and prevents end ogenous and exogenous chemicals fro m producing an effect on that receptor.
an xiety The apprehens ive anticipation of future danger or misfortlme accompanied by a feeling of d ysphoria or somatic symptoms of te ns ion. The focu s of an ticipa ted danger may be internal or extemal. aphasia An impainnent in the understanding or transmission of ideas by language in any of its fo rms-reading, writing, or speaking- that is due to injury or disease of the brain cen ters involved in language. aphonia An inability to produce speech sounds tha t require the use of the larynx that is not due to a lesion in the central nervous system. ataxia Partial or comple te loss of coordination of \foluntary muscular movement.
attention The ability to focus in a s ustained manner on a particular stimulus or activity. A dis turbance in attention may be manifested by easy distractibility or difficulty in finis hing tasks or in concentrating on work. avolition An inabili ty to initiate and persis t in goal-directed activities. Whe n severe enough to be considered patho logical, avolition is pervas ive and prevents the person from completing many different types of activities (e.g., work, intellectual pursuits, self-care). catalepsy Waxy fle xibility-rigid maintenance of a body position over an extended period of time. cataplexy Epis odes of sudden bila teral loss of muscle to ne resulting in the individual collapsing, often in associa tion with intense emotions s uch as laughter, anger, fear, or s urprise. cata tonic behavior Marked motor abnormalities including motoric immobility (i.e., catalepsy or s tupor), certain types of excessive motor activity (apparently purposeless
821
agitation not influenced by ex lernal stimuli), extreme negntivism (apparent motiveless resistance to instructions o r attempts 10 be moved) or IIIlltism, posturing or stereotyped movemeJlts, and echolalin or echopraxia. conversion symptom A loss of, or alteration in, voluntary motor or sensory functionin g suggesting a neurological or general medical condition. Psychological fa ctors are judged to be associated with the development of the symptom, and the symptom is not fully explained by a neurological or general medical condition or the di rect effects of a substance. The symptom is not intentionally produced or feigned and is not culturally sanctioned. defen se mechanism Automatic psychological process that protects the individual agains t anxiety and from awareness of i.nternal o r exlemal stressors or dangers. Defense mechani sms mediate the individual's reaction to emotional conflicts and to external stressors . Some defense mechanisms (e.g ., projection, splitting, and acting out) are almost invariably maladaptive. Others, such as suppression and denial, may be either malad aptive or adaptive, depending on their severity, their inflexibility, and the context in which they occur. Definitions o f s pecific defense mechanisms and how they would be recorded using the Defensive Functioning Scale are presented on p.807. delusion A false belief based on incorrect inference about external reali ty that is finn ly su stained despi te what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person' s culture or s ubculture (e.g ., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility . Delusional conviction occurs on a con tinuum and can sometimes be inferred from an individual's behavior. It is often difficult to dis tinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firml y as is the case with a delusion). Delusions are s ubdivided according to their content. Some of the more common types are listed below : bizarre A delusion that involves a phenomenon that the p erson's culture would regard as totally implausible. delusional jealousy The delusion that one's sexual partner is unfaithful. erotomanic A delusion that another person, usually of higher status, is in love w ith the individual. grandiose A delusion of inflated worth, p ower, knowledge, identity, or special relationship to a deity or famous person. mood-congruent See mood -congruent p sychotic features. mood-incongruent See mood-incongruent psychotic features. of being controlled A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under one's own control. of reference A delusion whose theme is that events, objects, or other persons in on e's immediate environment have a particular and unusual significance.
Appendi x C These delusions are u s ually of a negative or pejorative nature, but also may be grandiose in con tent. This differs from an idea of referellce, in which the fal se belief is not as firmly held nor as fu lly o rganized into a true belief. persecutory A delusion in which the cen tral theme is that one (or someone to whom one is close) is being attacked , harassed , cheated, persecuted, or conspired against. som atic A delu sion whose main content pertains to the appearance or functioning of one's body. th ough t broad casting The delusion that one' s thoughts are being broadcasl ou t loud so that they can be perceived by others. thoug ht insertion The delusion that certain of one's thoughts are not one's own, but ra ther (Ire inserted into one's mind. dep ersonali zati on An al teration in the perception or experience of the self so tha one feels detached from , and as if one is an outside observer o f, one's mental proces' es or body (e.g., fee ling like one is in a dream). derailment ("loosening o f associations") A pattern of speech in which a persO! ) ideas slip off one track onto another that is completely unrelated or only obHquely related. In moving fro m one sentence or clause to another, the person shifts the topic idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack a meaningful relations hip. This dis turbance occurs betwee" clauses, in contras t to incoherence, in which the dis turbance is withill clauses. An occasional change of topic without warning or obvious connection does not constitu te derailment. derealization An alleration in the perception or experience of the external world so that it seems s trange or unreal (e.g., people may seem unfamiliar or m echanical). disorien ta tion Confusion about the time o f day, date, or season (time), where one is (place), or who one is (person). dissocia ti on A d is ruption in the u sually integ rated hmct'ions of consciousness, memory, identity, or perception of the environment. The dis turbance may be sudden o r gradual, transien t or chron ic. dis trac tibility The inability to maintain attention, th at is, the shifting from one area or topic to another w ith minimal provoca tion, or attention being drawn too frequently to unimportant or irreleva nt external s timu li. dysarthria d yskinesia Imperfect articu la tion of speech d ue to disturbances of muscular control. Dis tort'ion o f voluntary movements w ith in voluntary muscular activity.
dyssomn ia Primary d isorders of sleep or wakefulness characterized by insomnia or hypersomnia as the major p resenting symptom . Dyssomnias are disorders of the amount, qu ality, or timing of sleep.
823
echolalia llle pathologica l, parrottike, and apparently senseless repetition (echoing) o f a word or phrase just spoken by another person. echopraxia Repetition by imitation of the movements of another. The action is not a willed or voluntary one and has a sem iautomatic and lmcontrollable quality. fla shback past.
A recurrence of a memory, feeling, or perceptual ex perience from th e
fli gh t of ideas A nearly continuous flo w of accelerated sp eech with abrupt changes from topic to topic tha t are usually based on understandable associations, d istracting stimuli, or plays on word s. When severe, speech may be d isorganized and incoherent. gend er dysp horia A persistent aversion toward some or all of those physical characteristics or social roles tha t connote one's own biological sex. gend er id enti ty A person's inner conviction of being male o r fe male.
gender role Attitudes, patterns of beh avior, and personality a ttributes defined by the culture in which the person lives as stereotypically "masculine" or " femin ine" social roles. gran diosi ty An infla ted appraisal of one's worth, power, know ledge, importance, or identity. \OVhen extreme, grandiosity may be of delusional proportions. hallucination A sensory perception that has the compelling sense o f reality o f a true perception but that occurs w ithout external stimulation of the relevant sensory organ. Halluci nations should be distinguished from iIlusiol/s, in which an actual external stimulus is m isperceived or m isinterpreted . The person may or may not have insigh t into the fact that he or she is having a hallucination. One person with auditory hallucinations may recognize th at he or she is having a fa lse sensory experience, whereas another may be convinced that the source of the sensory experience has an independen t physical reality . The term hallucillation is not ordinarily applied to the fal se perceptions tha t occur during d reaming, while falling asleep (hypnngogic), or when awakening (hypllopompic). Transient hallucinatory experiences may occur in people without a menta l disorder. Types o f hallucinations include auditory A hallucination involving the perception of sound, most commonly of voices. Some clinicians and investigators would no t include those experiences perceived as coming from inside the head and would instead limit the concept of true auditory hallucinations to those sounds whose source is perceived as being external. Howe\'er, as used in OSM-rV, no distinction is made as to whether the source of the voices is perceived as being inside o r outside of the head .
1 824
Append ix C
mood-congruent See mood-congruent psychotic features. mood-incongruent See mood-incongruent psychotic features. olfactory A hallucination involving the perception of odor, such as of burning rubber o r d ecaying fish. somatic A hallucination involving the perception of a physical experience localized within the body (su ch as a feeling of electricity). A somatic hallucination is to be distinguished from physical sensations arising from an as-yel undiagnosed general medical condition, from hypochondriacal preoccupation with normal physical sensations, and from a tacti le hallucination. tactile A hallucination involving the perception of being touched or of something being under one's skin. The most common tactile halluci nations are the sensation of electric shocks and formica tioll (the sensation of something creeping or crawling on or under the s kin). vis u al A hall ucination involving sight, which may consist of formed images, s uch as of people, or o f unformed images, such as flashes of light. Visua l hallucinations shouJd be distinguished from illusions, which are misperceptions of real external stimuli. h yp eracusi s Painful sensitivity to sounds.
hypersomnia Excessive sleepiness, as evidenced by prolonged nocturnal sleep. difficulty maintaining an a lert awake state during the day, or undesired d aytime sleep episodes. ideas of referen ce The feeling that cas ual incidents and external events have a particular and unusual meaning that is sp ecific to the person. This is to be distinguished from a delusion of reference, in which there is a belief that is held with delusional conviction. illus ion A misperception or misinterpretation of a real external stimulus, s uch as hearing the rustling of leaves as the sow,d of voices. See also hallucination. inco herence Speech or thinking that is essentially incomprehensible to others because word s or phrases are joined together without a logical or m eaningful connection. TIlis dis turbance occurs willIill clauses, in contrast to d erailment, in which the dis turbance is between clauses. This has sometimes been referred to as "word salad" to convey the deg ree of linguis tic disorganization . Mildly ungrammatical constructions or idiomatic usages characteristic of particular regional or cultural backg rounds. lack of education, or low intelligence should n ot be considered incoherence. The term is generally not applied when there is evidence that the disturbance in speech is due to an aphasia.
Glossary of Tech nical Te rms insomnia A s ubjective complaint of d ifficulty falling or staying asleep or poor sleep quality. Types of insollmia include initi al in somnia Difficulty in falling asleep. middle ins omnia Awakening in the middle of the night followed by eventually falling back to sleep, but with difficulty. terminal insomnia Awakening before one's usual waking time and being unable to return to sleep . intersex con d iti on A condition in which an individual shows intemlingling, in various degrees, of the characteristics of each sex, including physical form , reproductive organs, and sexual behav ior. macropsia The visual perception that objects are larger than they actually are.
magical thinking The erroneous belief that one's thoughts, words, or actions will cause or prevent a specific outcome in some way that defies commonly tmderstood laws of cause and effect. Magical thinking may be a part of normal child development. micropsia The visual perception that objects are smaller than they actually arc.
mood A pervasive and sustained emotion that colors the perception of the world. Conunon examples of mood include depression, elation, anger, and anxiety. In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood refers to a more pervasive and sustained emotional "clima te." Types of mood include d ysphori c An unpleasant mood, such as sadness, anxiety, or irritability. elevated An exaggerated feeling of well-being, or euphoria or elation. A person with elevated mood may describe feeling "high, " "ecstatic," "on top of the world," or "up in the clouds." eUlhymic Mood in the "normal" range, which implies the absence of depressed or elevated mood . exp an Sive lack of restraint in expressing one's feelings, frequentl y with an overvaluation of one's significance or importance. irritab le Easily arulOyed and provoked to anger. mood-cong ruen t p sychoti c features Delusions or hallucinations whose content is entirely consistent with the ty pical themes of a depressed or manic mood. U the mood is depressed, the content of the delusions or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may includc themes of persecution if these arc based on selfderogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions or hall ucina tions would involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person . The content of the delusion may include themes of persecu tion if these are based on concepts such as inflated worth or deserved punishment.
826
moodincongruent psychotic features
Appendix C
is n ot consistent with the typical themes of a depressed or manic mood. In the case of depression, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism , or deserved plmishment. In the case of mania, the delusions or hallucinations would not involve themes of inflated worlh, power, knowledge, or identity, or a special relationship to a d eity or a famou s person. Examp les of mood-incong ruent psychotic fea tures include persecutory d elusions (witho ut sel f-derogator)' or grandiose content), thought insertion, though t broadcast-
ing, and delusions of being controlled whose content has no apparent relationshi p to
any of the themes listed above. nystagmus Involuntary rhythmic movements of the eyes that consist of smallamplitude rapid tremors in one direction and a larger, slower, recurrent sweep in the opposite direction. Nystagmus may be horizontal, vertical, o r rotary. ovelValued idea An unreasonable and susta ined belief that is maintained wi th less than d elusionaJ intensity (i.e., the person is able to acknowledge the p ossibility that the belief may not be true). TIle belief is not one that is ord inarily accepted by other members of the person 's cu lture or subculture. panic allacks Discrete periods of sudden onset of intense apprehension, fearfulness, or terror, o ft en associa ted with feelings o f imp ending d oom. Du ring these attacks there arc symptom s such as shortness of breath or smothering sensa tions; palpitations, pounding heart, or accelerated heart rate; chest pain or discomfort; choking; and fear o f goi ng crazy or losing cont:rol. Panic attacks may be unexpected (uncued), in which the onset o f the attack is no t associa ted with a situational trigger and instead occurs "out of the blue"; situationally bound, in w hich the panic attack almost invariably occurs immediately on exposure to, or in anticipation of, a situation al trigger ("cue"); and situationally predisposed, in which the panic attack is more likely to occur on exp osure to a situational trigger bu t is not invariably associated w ith it. paranoid ideat ion Ideation, of less than d elusional proportions, involving suspiciousness o r the belief that one is being harassed , persecuted, or unfairly treated. parasomnia Abnormal behavior or physiological events occurring during sleep or sleep-wake transitions. personality Enduring patterns of perceiving, relating to, and thinking about the environment and oneself. Perso flnlity traits are prom inen t asp ects of personality thai are exhibited in a wide range of important social and personal contexts. Only when personality traits are inflexible and maladaptive and ca use either significant ftmctional impairment or subjective d istress do they constitute a Persona lity Disorder. phobia A persisten t, irra tional fear of a s pecific object, activity, or situation (the phobic stimulus) that results in a compelling desire to avoid it. This often leads either to avoidance of the phobic stimulus or to enduring it with dread.
Glossary o f Techn ical Terms pressured speech Speech that is increased in amount, accelerated, and difficult or impossible to interrupt. Usually it is aJso loud and emphatic. Frequently the person talks without any social stimulation and may continue to talk even though no one is listening. prodrome
An early or premonitory sign or symptom of a disorder.
See agitation.
Visible generalized slowing of movements and speech.
psychotic This term has historically received a number of different definitions, none of which has achieved universal acceptance. The narrowest definition of psycllotic is restricted to delusion s or prominent h allucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition would also include prominen t hallucina tions that the individual realizes are hallucinatory experiences. Broader still is a definition that also includes other positive symptoms of Schizophrenia (Le., disorganized speech, grossly d isorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in OSM-n and IC D-9 was probably far too inclusive and focused on the severity of functionaJ impa irment, so that a mental disorder was termed psychotic if it resulted in "impairment that grossly interferes w ith the capacity to meet ordinary demands of life." Finally, the term has been defined conceptually as a loss of ego boundaries or a gross impairment in reality testing. Based on their ch aracteristic features, the different disorders in OSM-IV emphasize different asp ects o f the various d efinitions of psychotic. residual phase The phase of an illness that occu rs after remission of the fl orid symptoms or the full synd rome. sex A person's biological status as male, female, or uncertain. Depending on the circumstances, this determin ation may be based on the appearance of the external genitalia or on karyotyping. sign An objective manifestation of a pathological condition. Signs are observed by the examiner rather than reported by the affected individual. stereotyped movements Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, h ead ban ging, mouthing of objects, self-biting, picking at skin or body o rifices, hitting one's own body). stressor, psychosocial Any life event o r life change that may be associated temporally (and perhaps causally) with the onset, occurrence, or exacerbation of a mental disorder. stupor A state of unresponsiveness with immobility and mutism .
828
Appendix C
symptom A subjective manifestation of a pathological condition. Symptoms are reported by the affected individual rather than observed by the examiner.
synd rome A grouping of signs and symptoms, based on their frequent co-occurrence, that may suggest a common underlying pathogenesis, course, familial pattern, or treahnent selection .
synesthesia A condition in which a sensory experience associa ted with one modality occurs when another modality is stimula ted , for example, a sound produces the sensation of a particular color.
tic An involuntary, sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.
transsexualism Severe gender dysphoria, coupled with a persistent desire for thp physical characteristics and social roles that connote the opposite biological sex.
Appendix D
T his appendix provides an overview of the changes made to the tex t. It should be noted that the followin g is not an exhaustive guide changes in wording made fo r clarity and expansions of the differentia l diagnosis sections of the text are not included here. It should also be noted that the majority of parag raphs in DSM-IV have not been revised, indicating tha t, even after the literature review, most of the information in the original text remains up-ta-date.
Introd uction . Several paragraphs have been added describing the DSM-IV text revision process, and additional clari fying text has been added to the Use of Clinical Judgment section regarding the importance of the method of data collection in determining whether diagnostic criteria have been met.
Multiaxial assessm en t. The instructions for making a Global Assessment of Func* tioning (GAF) rating have been greatly expanded. Discussions about applying the GAF to the curren t time frame and about the lmderlying struchlre o f the sca le (Le., each element's having a symptom and fun ctioning component) ha ve been added. Finally, a fOUT*step method to ensure that no elements of the GAF scale are over* looked when making a GAF rating is provided .
829
830
Appendix 0
Autistic Disorder. The lext in the Diagnostic Features section has been modified to highlight difficulties in the pragmatic aspects of language, which are especially relevant in the assessment of higher-functioning individuals. In addition, better examples of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities have been added. The text has also been modified to reflect evidence that in
up to one-fifth of cases, parents retrospectively report relatively normal development for the firs t 1 or 2 years. The section on associa ted cognitive deficits and associated general medical conditions has been updated. The range of prevalence figures has been revised to reflect a number of more recent studies that suggest a higher prevalence. More specific infonnation regarding sibling risk has been added to the Familial Pattem section.
Rett's Disorder. Text has been added reflecting the finding that some cases of Rett's Disorder are associated with a specific genetic mutation. Asperger's Diso rder. Because of the limited data available about this newly introduced disorder, the DSM-IV text for Asperger's Disorder provided little more than a restatement of the diagnostic criteria. Accordingly, the text for Asperger's Disorder has now been extensively revised. Specific examples of the typical manifestations of the impainnent in reciproca l social interaction and in restricted, repetitive behavior and interests are provided in order to better differentiate these individuals from those with Autistic Disord er. In addition, text has been added to clarify that the requirement for no clinically significant delays in language does not imply that individuals with Asperger's Disorder have no problems with communication. The Associated Features and Disorders, Course, and Differential Diagnosis sections have been greatly expanded and a section on Specific Age Features has been added. Pervasive Developmental Disorder Not Othenvise Specified. The definition has been changed to correct an error that inadvertently allowed this diagnOSis to be made in cases in which there was a pervasive impairment in only one developmental area (i.e., in the development of reciprocal social interaction, communication skills, or stereotyped behaviors, interests, or activities). The definition now requires that there be impairment in reciprocal social interaction that is associated with an impairment in communication skills or with the presence of stereotyped beha viors, interests, or activities. Atiention-D eficitlHyperactivity Disorder. Many of the changes highlight differences among the subtypes. For example, individuals with the Predominantly Inatten tive and Combined Types tend to have academic deficits and school-relate< problems, whereas those with the Predominantly Hyperactive-Impulsive Type tena to have more peer rejection and accidental injuries. Gender ratio is less predominantly male in the Predominantly Inattentive Type. Additional information about Associated Features (e.g., variability in IQ presence of family discord) and Specific Age Features (especially Attention-Deficit/ Hyperactivity Disorder in adults) is in cluded. Estimates of prevalence rates have been revised upward, reflecting increased prevalence due to the inclusion of the Predominantly Hyperactive-Impulsive and Predominantly Inattentive Types in DSM-IV.
831
Conduct Disorder. The list of risk factors for developing Conduct Disorder has been expanded. The relationship between Oppositional Defiant Disorder and the subsequent development of the Childhood-Onset Type oCConduc! Disorder has been noted in the Course section. Oppositional Defiant Disorder. The Course section of the text clarifies that although Childhood-Onset cases of Conduct Disorder are often preceded by Oppositional Defiant Disorder, many children with Oppositional Defiant Disorder do not go on to develop Conduct Disorder. Pica. Prevalence data have been provided, and comorbidity with Pervasive Developmental Disorders is noted . Feeding Disorder of Infancy or Early Childhood. Changes have been made in the Prevalence (community prevalence is noted) and Course sections (persistence of decreased height and weight into adolescence compared with peers). Tic Disorders. The DSM-N criteria set for Tic Disorders has been corrected by eliminating the requirement (or "clinically Significant distress or impairment" that was added to the majority of disorders in OSM-N (Tic Disorders among them). This criterion has been problematic in Tic Disorders (or a number of reasons, including the fac t that it is at variance with clinical experience (i.e., most children w ith Tourette's Disorder do not experience marked distress or impairment) and that it hinders epidemiological research and famil y studies. Other changes in the text include an expanded description of the types of tics as well as an expansion of the Differential Diagnosis section (i.e., differentiating between tics and o ther types of movements) and of the Associated Features and Disorders (including comorbid ity patterns), Specific Age Fea tures (gender ratio), Prevalence, Course, and Familial Pattern sections of Tourette's Disorder. Encopresis. Encopresis with functional constipation is the most common form. Text regarding phYSiological predispositions to constipation has been updated and expanded . Enuresis. lew information about different mechanisms underlying the Diurnal Only Type has been added. Associa ted Features and Disorders (particularly predisposing fa ctors), Prevalence, and Familial Pattern sections have been updated . Separation Anxiety Disorder. The Prevalence and Course sections have been updated to indicate that there is a decrease in prevalence from childhood through adolescence and that mosl children with separation anxiety are free of an impairing Anxiety Disorder at extended follow-up. Reactive Attachment Disorder. The Associated Features and Disorders (risk factors such as extreme neglect and institutional care) and Course (persistence of indis~ criminant sociability) sections have been updated.
Appe nd ix 0 Stereo typic Movement Disord er. Pathological skin picking has been removed from the list of examples-such cases should be diagnosed as Impulse-Control Disorder I ot Otherwise Specified. The Associated Features and Disorders section (i.e., clarification that the disorder can occur in non-developmen tally delayed populations) has been modified .
as yet widely accepted. Text has been added 1 the Associated Laboratory Findings 0 subsection (as weU as the Differential Diagnosis section for Dementia) acknowledging that Alzheimer's disease remains a diagnosis of exclusion. The section on Course has been u pdated to highligh t the development of personality changes. Prevalence estimates have been revised on the basis of the United States General Accounting Office's 1998 report on the prevalence of Alzheimer's disease. Finally, the Familial Pattern section has been updated to refl ect current data on cruomosomal linkage and the role of the genetic marker APOE4 as a risk fa ctor for the development of late-onset cases. Dementia Due to Parkinson's Disease/Dementia Due to Pick's Disease. Two of the most common form s of dementia are Lewy body dementia (an example of which is Dementia Due to Parkinson's Disease) and frontotemporal dementia (of which Dementia Due to Pick's Disease is an example). Although there was insufficient evidence to justify a radical reorganization of this section, text has been added to the sections on Dementia Due to Other General Medical Conditions, Dementia Due to Parkinson's Disease, and Dementia Due to Pick's Disease to clarify how such cases should be classified. Dementia Du e to Creutzfeldt-Jakob Disease. Text has been added regarding Ihe cross-species transmission of prion infections, reflecting the outbreak of a human \'ariant of bovine spongiform encephalopathy in the United Kingdom in the mid1990s.
Substance-Related Disorders
Substance Dependence. The Features section has been updated to ind icate that varied deg rees of tolerance may develop to the different central nen'ous system effects of a substance, that tolerance may develop to phencyclidine, and that a past history o f tolerance or withd rawal is associated with a worse clinical course (i.e., earlier onset, higher levels of substance intake, and greater numbers of substance-related problems).
Append ix 0 Familial Pattern sections for Depend ence/AbuselIn toxication/Withd rawal. The text has been updated to clarify that individuals who may be at higher risk for Alcohol Dependence because of a family history of Alcohol Dependence do not necessar ily have a higher risk of developing Dependence on other substances. Substance-Induced Disorders. Examples have been added to help clarify when it is appropriate to diagnose Substance Intoxication or Substance Withdrawal versus a SubstanceInduced Disorder With Onset During Intoxication or With Onset During Withdrawal. Alcohol-Related Disorders. The Associated Features and Disorders section (e.g., risk of a1cohol related accidents, comorbidity with o ther disorders) has been updated. A discussion of the laboratory test carbohydrate deficient transferrin (COn, a widely used state marker for heavy drinking, has been added. In the Specific Culture, Age, and Gender Features section, the text concerning the low rates of Dependence in Asians and the clinical course in women has been expanded. Text regarding the prevalence of alcohol use, alcohol~rela ted complications, and Alcohol Dependence has been expanded and updated . Amphetamine (or Amphetamine-Like)-Relaled Disorders. Text regarding the prevalence of amphetamine use across different age groups and the prevalence of Dependence has been expanded and updated. Caffeine-Relat ed Di sorders. The Specific Culture, Age, and Gender Features section has been expanded 10 include infonnation about the increased sens itivity of the elderly to the effects of caffeine. A Prevalence section has been added that describes patterns of caffeine use, and the Course section has been expanded and updated . Cannabi s-Related Disorders. Updated infonnation regarding mechanisms of action has been added to the introductory section . The text for Cannabis Dependence has been updated to clari fy that evidence of physiological dependence is seen in chronic users and may be associated with more severe cannabis-related problems. Text regarding the prevalence of cannabis use across different age groups and the prevalence of Dependence has been expanded and updated. A d iscussion of whether cannabis use is a precursor to other drug use (i.e., its role as a "gateway drug") has been added to the Course section. Cocaine-Related Disorders. The complications of severe Cocaine Intoxication have been updated and expanded, and the Specific Culture, Age, and Gender Features section has also been updated. Text regarding the prevalence of cocaine use across different age groups and the prevalence of Dependence and Abuse has been expanded and upd ated. Hallucinogen-Related Di sorders. A discussion of the physiological changes associated with in toxica tion (e.g., increases in blood glucose) has been added. Text regarding the prevalence of hallucinogen use across different age groups and the prevalence of Dependence and Abuse has been expanded and updated.
Inhalant-Related Disorders. Additional information has been added to the subsections on Associated Labora tory Findings (Le., the availability of urine assay for a metabolite of toluene) and Associated Physical Examination Findings and General Med ical Conditions (i.e., an expanded list of respiratory complications and discussion of a possible association between benzene and acute myelocy tic leukemia) . Text regarding the prevalence of different types of inhalant use among differen t age and other demographic groups has been added. Nicotine-Related Disorders. The Specific Culture, Age, and Gender Features section has been updated (e.g., data about increased nicotine blood levels in African Americans have been added). Text regarding the prevalence of smoking and other tobacco use in various groups and the prevalence of Nicotine Dependence has been updated. The Course section has also been revised on the basis of new data . Opioid-Related Disorders. Text regarding hepatitis screening tests has been added to the Associated Laboratory Findings subsection, and death rates from medical complications have been added to the Associated Physical Examination Findings and General Medical Conditions subsection. The Specific Culture, Age, and Gender Fea~ tures (i.e., gender ratio) and Course (i.e., remission rates) sections have been updated. Text regarding the prevalence of different patterns of opioid use among different age and other demographic groups has been updated and expanded. Phencyclidine (or Phencyclidine-Like)-Related Disorders. Text regarding th eprev~ alenceof different patterns of phencyclidine use among different age groups has been updated and expanded. Sedative-, Hypnotic-, and Anxiolytic-Related Disorders. Text regarding patterns of use among different age groups and the prevalence of Dependence and Abuse has been updated. Polysubstance Dependence. use of this category. Examples have been added to clarify the appropriate
I
1836
Appendix D
cases, and upda ted text regarding gender d ifferences. The Prevalence section has been updated to include add itional information and geogra phic and historical variations in incidence. The Familial Pattern section introd uces the concept of "schizophre-
nia spectrum " (i.e., the range of disorders that are more likely in the relatives of
individuals with Schi zophrenia). Schizophrenia Subtypes. The introduction has been updated to ind icate limited stabili ty and prognostic vaJue of the subtypes.
including contrasting ra tes in developed and developing countries. A b rief Familial Pattern section has been added, indicating a p ossible increased risk of Schizophrenia in relatives of indiv iduals with Schizophreniform Disorder. Sch izoaffective Disorder. The Specific Culture, Age, and Gender Features (i.e., ele vated rates in women are mostly accounted for by increased incidence of the Depres sive Type) and Course (i.e., association of stressors with a better prognosis) sections have been updated. Delus ion al Disorder. The Course section has been updated. Brief Psychotic Disorder. The Prevalence section has been u pdated to note that al though this disorder is rarely seen in developed countries, psychotic episodes 0 slightly longer d uration (1-6 months) are morc common in d eveloping countries. Psychotic Diso rder Due to a General Medi cal Co nditi on. The lis t of etiological general medical conditions has been updated, and sections on Prevalence and Course have been added.
Mood Disorders
Ma jor Depressive Episode. The Associated Laboratory Findings subsection of the text has been updated and expanded to incl ude additi onal neurobiological abnormal ities (e.g., alterations in neuropeptides and other hormones in response to challenge tests) and functional brain imaging results. The Specific Culture, Age, and Gender Features section has been updated to clarify that increased risk in women emerges during adolescence and rna}' coincide with puberty. Major Dep ressive Disorder. The Associa ted Physical Exam ination Findings and General Medical Conditions su bsection has been updated to emphasize tha t comor bid general medical conditions worsen the course of Major Depressive Disorder. The Specific Culture, Age, and Gender Features section has been expanded to include in formation abou t labora tory fi ndings (e.g., evidence of s ubcortical white matter hyper intensities) in late-onset depression. Changes in the Familial Pattern section indicate increased risk of Anxiety Disorders in offspring of individuals with depression. Dysthymic Di sorder. The Course section has been updated to indicate that the out come o f Dysthymic Disorder is Significan tly better with active treatment. Changes to
837
the Familial Pattern section indicate elevated rates of both Dysthymic Disorder and Major Depressive Disord er in relatives o f those with Dysthy mic Disorder. Bipolar I Disorder and Bipolar II Disorder. The Associated Descriptive Features and Mental Disorders subsection has been expanded to include informa tion on the comorbidity of Bipolar I Disorder and Alcohol and other Substance Use Disorders. The Associated Labo ratory Findings subsection has been updated to reflect increased rates of certain brain lesions in indh' iduals with Bipolar I Disorder as a group. The Associated Physical Examination Findings and General Medical Conditions subsection has been expanded to clarify the relationship between Bipo lar I and Bipolar II Disorders and thyroid d ysfunction (i.e., association between hypo function and rapid cycling, and hyperthyroidism precipitating episodes in those with preexisting Mood Disorder). The Specific Culture, Age, and Gender Features section has been updated to reflect gender differences in Rapid Cycling, types of episodes, and risk for mixed episodes. The relationship between age at onset and famil y history is noted in the Familial Pattern section o f Bipolar I Disorder. Bipolar Disorder Not Otherwise Specified. An additional example has been added to clarify that individ uals w ith chronic d ysthymia who also experience occasional hypomanic episodes do not qualify for a diagnosis of either Dysthymic Disorder (because hypomanic episodes are present) or Cyclothymic Disorder (because the hypomanic episodes are too infrequent). Catatonic Features. causes of cata tonia . The text has been expanded to provide a breakdown o f the
Melancholi c Features. The original statement that ind ividuals with Melancholic Features a re more likely to respond to somatic trea tment is inco rrect and has been replaced by tex t that emphasizes the need for active treahllent given the low placebo response rate. Atypical Features. Text has been added to clarify that, when used to d esc.ribe the most recent (as opposed to current) episode, this specifier applies if the fea tures p redominate during any 2-week period. In addition, it is noted that individ uals with these features are more likely to respond to treatment w ith monoamine oxidase inhibitors than to tricyclic antidepressants. Postpartum Onset. The text on associated features has been updated, and text has been added to highlight the differentiation of this subtype from "baby blues." Rapid Cycling. Updated text includes prevalence data and the potential association between cycling rate and antidepressant therapy.
Anxiety Disorders
Panic Attack. The text describing the three typ es of Panic Attacks (Le., unexpected , situationally bOlU1d, and situationally predisposed) has been updated to cla rify the
1 838
Appendix 0
nature of the triggers, the association between the types of Panic Attacks and particular Anxiety Disorders, and differentia l d iagnosis. Panic Disorder. Information about the relationship behveen Panic Attacks and potential triggers in Panic Disorder has been upda ted (i.e., situational triggers may be e ither external or internal, and "unexpected" means that the individual does not immediately associate the attack with a situational trigger). The list of associated general medical conditions has been extended, the Prevalence section has been expanded to include rates in clinical samples, and the Familial Pattern section has beat updated to include information from more recent studies (e.g., relationship behveen age at onset of proband and risk in first-degree relatives). Finally, the Differential Diagnosis section has been expanded to include situations in which the person may not be able to identify the cues triggering a Panic Attack (e.g., cognitions or physiological symptoms similar to those that occurred at the time of the traumatic event in Posttraumatic Stress Disorder).
Specific Phobia . Additiona l information regarding comorbidity, relative frequ ency of subtypes in community settings, gender ratio, course (e.g., having Specific Phobia in adolescence increases the chance of having Specific Phobia in adulthood but not other mental disorders), and familial pattern has been provided. Social Phobia. The Associa ted Descriptive Features and Mental Disorders section has been updated (i.e., association with suicidal ideation and othe r Anxiety Disorders). The Associa ted Laboratory Find ings subsection has been updated to c1arify that no laboratory test has been found to be diagnostic of Social Phobia (i.e., original text suggesting a d iffe rential response to lactate infus ion has been dele ted). Obsessive-Compulsive Disorder. Information regarding comorbidity WiOl other mental disorders has been updated . The Specific Cultu.re, Age, and Gender Features section has been updated to inc1ude a brief section on the subset of childre n who develop Obsessive-Compulsive Disorder in association w ith Group A beta-hemolytic s treptococcal infections. Additional information has been added to draw on the increased body of data regarding children w ith Obsessive-Compulsive Disorder (e.g., comorbid disorders, prevalence) . The Prevalence section has been updated and expanded to include rates in children. Posttraumatic Stress Disorder. Informa tion regarding associated fea tu res, comorbidity with other mental d isorders, associations with general medical conditions, prevalence rates, and course (e.g., symptom reactivation in response to reminders of trauma, life stressors, or new traumatic events) has been updated. A brief Familial Pattern section has been added, describing evidence of a heritable component to the transmission of Posttraumatic Stress Disorder and the relationship between a his tory of depression in first-degree relatives and increased vulnerability to developing Posttrauma tic Stress Disorder. Acute Stress Disorder. Additional information regarding progression to Pos ttraumatic Stress Disorder and a range of prevalence rates in individuals exposed to severe traumas have been provided.
839
Generalized Anxiety Diso rder. Prevalence in clinical settings and familia l pattern (i.e., evidence from h .... in studies that suggests a genetic contribution) have been updated.
Somatoform Disorders
Somatization Disorder. The Associated Physical Examination Findings and General Medical Conditions subsection has been updated to clarify that some individuals with Somatization Disorder also have objective signs that are part of a comorbid general medical condition. Conversio n Disorder. The Prevalence section has been expanded to include rates in certain general medical settings. Pain Disorder. The discussion on the risk of iatrogenic Substance Dependence in the Associated Features and Disorders section has been updated and expanded to include factors that minimize the likelihood of developing ia trogenic Substance Dependence.In add ition, text on associated sleep problems has been expanded. Text addressing the prevalence of Pain Disorder in clinical settings, as well as additional infonnation about course, has been included. Hypochondriasis. The Associated Features and Disorders, Prevalence, and Course (i.e., factors associated with better prognosis) sections have been updated. Body Dysmorphic Disord er. Body build and muscularity have been added to the list of body site preoccupations. The Associated Features and Disorders section has been updated 10 include additional infonnation about Jack o f insight and efforts to correct or hide Ihe defects. Reported prevalence ra tes in clinical settings are also included.
Factitious Disorders
Factitious Disorder. The revised tex t for the Predominantly Physical Signs and Symptoms subtype more dearly differentiates Mlinchausen's syndrome (the most severe and chronic fonn of Factitious Disorder) from less severe, more transient forms. A Specific Gender Features section has been added, and the Prevalence and Course sections have been updated .
Dissociative Disorders
Dissociative Identity Disorder. The text has been modified to indicate that cases of Dissocia tive Identity Disorder ha ve been documented in a variety of cultures a round the world. Depersonalization Disorder. The Associated Features and Disorders and Course sections have been updated.
1 840
Appendix 0
Highlights of Changes in I
N arcolepsy. Text has bee gogic and hypnopompic t with normal sleep. The A~ section and Course (age , updated . A Specific Age FI agnosis of Narcolepsy in ci Breathing-Related Sleep I ciated PhYSical Examinatic tion beh\'een neck size ani Age and Gender Featu res Circadian Rhythm Sleep been proVided in the Asso tory Findings and Associ. Conditions subsections, ar Pattern sections. O yssomn ia Not Othem'i legs syndrome and periae includ ed in the lnlernatiOi N ightmare Disorder. n subsection (i.e., an associ; symptom measures of ot~ quent nightmares in youn
Gender Iden tity Disorder. Additiona l information is included to clarify how the subty pes (based on se>.:ual attraction) differ in terms of associa ted features and cou rse.
Eating Disorders
Anorexia Nervosa. The Associa ted Features and Disorders section has been updated to include comorbidity w ith Personality Disorders. The Prevalence section has been expanded to include fig ures for males. Course features have been updated to clarify the relationship between Anore>.:ia Nervosa and Bulim ia Nervosa. Bulimia Nervosa. Course section has been updated to include some information on the long-term ou tcome of Bulimia Nervosa.
Sleepwalking Disorder. Specific Culture, Age, and sections have been updal(
Sleep Disorders
Primary Insomnia. The Associated Descriptive Features and Mental Disorders subsection (e.g., functional impairment) and Associated Laboratory Findings subsection (e.g., lack of daytime sleepiness as measured by Multiple Sleep Latency Test IMSLT], substan tial discrepancies beh\'een subjective report and polysomnographic measures of sleep quality) have been revised. The Specific Age and Gender Features (e.g., in the elderly). Prevalence (e.g., rates of the disorder in the general population), Course (text on chronicity), and Familia l Pattern sections have also been u pdated . Primary Hypersomnia. The Specific Age and Gender Features (e.g., in children), Prevalence, and Course sections have been updated.
Iml
Nc
Intermittent Explosive [ sa ultive acts include verb sociated Features and OJ and Menial Disorders su gressive acts, such as ti Course sections have bee cating those d isorders t individua ls wi th lntermi tion.
Appendix 0
841
isorders
the terms gender identity,
Narcolepsy. Text has been added to clarify that some of the symptoms (i.e., hypnagogic and hypnopompic hallucinations and sleep paralysis) a lso occur in persons with normal sleep. The Associated Laboratory Findings (including HLA typing) subsection and Course (age at onset vs. age at presentation) section have also been updated . A Sp ecific Age Fea tures section has been added to address issues in the diagnosis of Narcolepsy in children. Breathin g-Related Sleep Disorder. The Associated Laboratory Findings and Associa ted Physica l Examination Findings an d General Medical Conditions (i.e., association between neck size and risk for obstructive sleep apnea) subsections and Specific Age and Gender Features (i.e., in child ren) section have been updated. Circadian Rhythm Sleep Disorder. Addi tional subtype-specific information has been provided in the Assodated Features and Disorders section, Associated laboratory Findings and Associated Physical Examination Findings and General Medical Conditions subsections, and Specific Age Features, Prevalence, Course, and Fami lial Pattern sections. Dyssomnia No t Oth envise Sp ecifi ed. Greatly expanded descriptions of restless legs syndrome and periodic limb movements, h\'o weU-established Sleep Disorders included in the Internationa l Classification of Sleep Disorders, are now included . Nightm are Disorder. The Associated Descriptive Fea tures and Mental Disorders subsection (i.e., an association behveen frequent chronic nightmares and increased symptom measures of other psychopathology) and the Prevalence (i.e., rates of fre~ quent nightmares in young adults) and Course sections have been updated. Sleepwalking Disorder. The Associa ted Laboratory Findings subsection and the Specific Cu lture, Age, and Gender Fea tures, Prevalence, Course, and Familial Pattern sections have been updated. Sleep Disorders Related to Another Men tal Disord er. The Associated Labora tory Features subsection has been updated .
to clarify that for Pedo?rson has acted on these or interpersonal difficulSad ism, if the person has rges, sexual fanta Sies, or then the clinical significal significance criterion lIy significant distress or reas of functioning. Of lar pa ttern of paraphilic
section has been updatPrevalence section has have been updated to tia Nervosa.
de Some information on
Mental Disorders subry Findings subsection la tency Test [MSLT], mnographic measures er Features (e.g., in the pulation), Course (text dated.
1842
Appendix 0
Highlights of Changes il
Kleptomania. The Associated Features and Disorders and Familial Pattem (Le., possible family history of Obsessive-.Compulsive Disorder in first-degree relatives of individuals with Kleptomania) sections have been upd ated. A Specific Gender Features section (i.e., gender ratio) has also been added.
Pathological Ga mbling. An Associated Laboratory Findings subsection (e.g., a variety of abnormalities reported in samples of males) has been added. The Associa ted Fea tures and Disorders (e.g., childhood history of ina ttentive or hyperactive symptoms) and Prevalence (e.g., infl uence of availability of legalized gambling on the prevalence of Patho logical Gambling) sections have been upda ted .
T rich otillomania. The Associated Features and Disorders, Prevalence, and Course sections ha ve been updated.
Changes have been mac made in the descripti ve I postpsychotic d epressivE der. mixed anxiety-depr Movement Disorders sec pendixes E, F, and G havi have taken place over the OSM-IV Text Revision a{
Adjustment Disorders
The Associated Features and Disorders section has been updated to clarify comorbidity with other disorders. The Prevalence section has been expanded to include rates in children and in particular clinical settings. The Course section now includes text about the risk of progression to other disorders.
Personality Disorders
Introductory Text fo r Personality Disord ers. The text describing dimensional models has been updated, presenting the dimensions in terms of some of the more important models. Antisocial Personality D isorder. The Associated Features and Disorders text has been updated to clarify that features that are part of the traditional conception of psychopathy may be more predictive of recidivism in settings (e.g., prisons) where criminal acts are likely to be nonspecific. Borderline Personality D isorder. Text has been added to the Course section to emphasize that, contrary to many clinicians' p reconceived notions, the prognosis for many individua ls with Bord erline Personality Disorder is good. Dependent Personality Disorder. The text for the Specific Culture, Age, and Gender Features section has been changed to remove the suggestions tha t reported gender difference is largely artifactual. ObsessiveCompul sive Personality D isorder. The Associated Features and Disord ers section has been updated to further clarify the relationship between Anxiety Disorders (especially Obsessive-Compulsive Disorder) and Obsessive-Compulsive Personality Disord er.
Appendi x D
843 1
Appendixes
Changes have been made to several of the appendixes. Small changes have been made in the descriptive text for some of the research categories in Appendix B (e.g., postpsychotic depressive disorder of Schizophrenia, premenstrual dysphoric disorder, mixed anxiety-depressive disorder), and the text for the Medication-lnduced Movement Disorders section has been updated to include atypical neuroleptics. Appendixes E, F, and G have been updated to correct for lCD-9-CM coding changes that have taken place over the past several }'ears. Appendix K, containing the names of the OSM-IV Text Revision advisers, has also been added .
gs subsection (e.g., a val added. The Associated 'e or hyperacth'e sympilized gambling on the dated.
ted to clarify comorbid)anded to include rates :oon now incl udes text
Course section to emlOS, the prognosis for l. uiture, Age, and GenlOS tha t reported gen-
Appendix E
309.28 309.4
V71.01
995.2 780.9
3QO.22
305.00
3Q3.90
291.89 291.89
291.1
291.2
291.5
291.3 291.89
291.89
3Q3.00 291.0
291.9 291.81
291.0
294.0
Academic Problem Acculturation Problem Acute Stress Disorder Adjustment Disord ers Unspecified With Anxiety With Depressed Mood With Disturbance of Conduct With Mixed Anxiety and Depressed Mood With Mixed Disturbance o f Emo tions and Cond uct Adult Antisocial Behavior Adverse Effects of Medication OS AgeRelated Cognitive Declin e Agoraphob ia Withou t His tory of Panic Disorder Alcohol Abuse Dependence -Induced Anxiety Disord er -Induced Mood Disord er -Induced Persis ting Amnes tic Disord er -Induced Persis ting Dementia -lnduced Psychotic Disorder With Delusions With Hallucinations -Induced SexuaJ Dysfun ction -Induced Sleep Disorder Intoxication Intoxication Delirium Related Disord er NOS WiUldrawal Withd rawal Delirium Amnestic Disorder Due to ... (Indica te fi,e Genernl Medical Conditioll }
845
846
294.8
305.70 304.40 292.89 292.84
Appendix E
292.11 292.12 292.89 292.89 292.89 292.81 292.9 292.0 307.1 301.7 293.84 300.00 Anxiety Disorder OS 299.80 Asperger's Disorder A tten tion-Defio t / H yperactivity Disorder 314.01 Combined Type 314.ot Predominantly Hyperactive-Impuls ive Type Predominantly Inattentive Type 314.00 314.9 Attention-Defict / Hyperactivity Disorder N OS 299.00 Autistic Disorder 301.82 Avoidant Personality Disorder V62.82 Bereavement 296.80 Bipolar Disorder NOS Bipolar r Disorder, Most Recent Episode Depressed 296.56 In Full Remiss ion 296.55 In Partial Remission 296.51 Mild 296.52 Moderate Severe Without Psychotic Features 296.53 Severe With Psychotic Features 296.54 296.50 Unspecified 296.40 Bipolar I Disorder, Most Recent Episode HypomaniC Bipolar I Disorder, Most Recent Episode Manic 296.46 In Full Remission In Partial Remission 296.45 Mild 296.41 Moderate 296.42 Severe Without Psychotic Features 296.43 Severe With Psychotic Features 296.44 296.40 Unspecified
Amnestic Disorder NOS Amphe tamine (or Amphetamine-Like) Abuse Dependence -Induced Anxiety Disorder -Induced Mood Disorder -Induced Psychotic Disorder With Delusions With Hallucinations -Induced Sexual Dysfunction -Induced Sleep Disorder Intoxication Intoxication Delirium -Related Disorder N OS Withdrawal Anorexia Nervosa Antisocial Personality Disorder Anxiety Disorder Due to ... Indicate tile General Medical C01lditio1l]
Bipolar I Disorder, Most Recent Episode Mixed 296.66 In Full Rem ission 296.65 In Partial Remission 296.61 Mild 296.62 Moderate Severe Without Psychotic Features 296.63 Severe With Psychotic Features 296.64 296.60 Unsp ecified 296.7 Bipolar I Disorder, Most Recent Episod e Unspecified Bipolar I Disorder, Single Manic Episode 296.06 In Fu ll Remission 296.05 In Partial Remission 296.01 Mild 296.02 Moderate 296.03 Severe Without Psychotic Features 296.04 Severe With Psychotic Features 296.00 Unspecified 296.89 Bipolar II Disorder 300.7 Body Dysmorphic Disorder V62.89 Borderline Intellectual Function ing 301.83 Borderline Personality Disorder 780.59 Breathing-Related Sleep Disorder 298.8 Brief Psychotic Disorder 307.51 Bulimia Nervosa Caffeine 292.89 -Induced Anxiety Disorder 292.89 -Induced Sleep Disorder 305.90 Intoxication 292.9 -Related Disorder NOS Cannabis 305.20 Abuse 304.30 Dependence 292.89 -Induced Anxiety Disorder -Induced Psychotic Disorder 292.11 With Delusions 292.12 With Hallucinations 292.89 Intoxication 292.81 Intoxication Delirium 292.9 -Related Disorder NOS 293.89 Catatonic Disorder Due to .. . {lfl dicate tile General Medical COflditiOIl} 299.10 Childhood Disintegrative Disorder \171.02 Child or Ad olescent Antisocial Beh avior 307.22 Chronic Motor or Vocal Tic Disorder 307.45 Circadian Rhythm Sleep Disord er Cocaine 305.60 Abuse 304.20 Depend ence
Append ix E
292.89
292.84
292.11 292.12 292.89 292.89 292.89 292.81 292.9 292.0 294 .9 307.9 31 2.81 312.82 312.89
In d uced Anxiety Disorder Ind uced Mood Disorder -induced Psychotic Disorder With Delusions With Hallucina tions -Induced Sexual Dysfun ction -Ind uced Sleep Disorder Intoxication Intoxication Delirium -Related Disord er NOS Withdrawa l Cognitive Disorder NOS Communica tion Disorder NOS Conduct Disorder Childhood-Onset Type Adolescent-Onset Type
Unspecified Type
300.11 Convers ion Disorder 301.13 Cyclothymic Disorder 293.0 Deli rium Due to ... (I lldicafe tile Gel/eral Medicnl COllditio ll] 780.09 Deli rium NOS 297.1 Delusiona l Disorder Dementia Due to Creutzfeldt-Jakob Disease 294.1O ~ Without Behaviora l Disturba nce With Behavioral Dis turbance 294.11 "
294.10 294.1P
29U O" 294.11" 294.10" 294.11" 294.10" 294.1P 2901.10" 294 .11" 294.100294.11 0294.8
Dementia Due to H ead Trauma W ithout Behaviora l Disturba nce With Behavioral Disturbance Dementia Due to HIV Disease Without Behaviora l Disturbance With Behav ioral Disturbance Dementia Due to Huntington's Disease Without Behavioral Dishubance With Behav ioral Disturbance Dementia Due 10 Parkinson's Disease Without Behavioral Distu rbance With Behavioral Disturbance Demen tia Due to Pick's Disease Without Behavioral Dishubance With Behavioral Disturbance llditioll} Dementia Due to . .. {JlIdicate Other Gelleral Medical CO Without Behavioral Dishubance With Behavioral Disturbance Dementia NOS
849
311 315.4
799.9
799.9
313.9
315.2
312.9
300.12 300.15 300.13 300.14 302.76 307.47 300.4 307.50 787.6 307.7 307.6 302.4 315.31
300.19
Dementia of the Alzheimer's Type, With Early Onset '''' ithout Behavioral Disturbance With Behavioral Disturbance Dementia of the Alzheimer's Type, With Late Onset Without Behavioral Disturbance With Behavioral Disturbance Dependent Personality Disorder Depersonalization Disorder Depressive Disorder NOS Developmental Coordination Disorder Diagnosis Deferred on Axis n Diagnosis or Condition Deferred on Axis I Disorder of Infancy, Childhood, or Adolescence NOS Disorder of Written Expression Disruptive Behavior Disorder NOS Dissociative Amnesia Dissociative Disorder NOS Dissociative Fugue Dissociative Identity Disorder Dyspareunia (Not Due to a General Medical Condi tion) Dyssomnia NOS Dysthymic Disorder Eating Disorder NOS Encopresis, With Constipation and Overflow Incontinence Encopresis, Without Constipation and O\' erflow Incontinence Enuresis (Not Due to a General Medical Condition) Exhibitionism Expressive Language Di sorder Factitious Disorder With Combined PsychologiC and Physical Signs and Symptoms al With Predominantly Physical Signs and Symptoms With Predominantly Psychological Signs and Symptoms Factitious Disorder NOS Feeding Disorder of Infancy or Early Childhood Female Dyspareunia Due to .. . {lndicnte tile Gel/ernl Medicnl Condition] Female H ypoactive Sexual Desire Disorder Due to . .. [l1Idicate Ihe Ge1leral Medical C01ldition] Female Orgasmic Disorder Female Sexual Arousa l Disorder Fetishism Frotteurism Gender Identi ty Disorder in Adolescents or Adults in Children Gend er Identity Disorder OS
850
300.02 Generalized Anxiety Disorder
Appendix E
305.30 304.50 292.89 292.84 292.11 292.12 292.89 292.81 292.89 292.9 301.50 307.44 302.71
300.7
313.82 312.30
307.42
312.34 312.32 315.9 296.36 296.35 296.31 296.32 296.33 296.34 296.30 296.26 296.25 296.21
Hallucinogen Abuse Dependence -Induced Anxiety Disorder -Induced Mood Disorder -Induced Psychotic Disorder With Delusions With Hallucinations Intoxication Intoxication Delirium Persisting Perception Disorder -Related Disorder NOS Histrionic Personality Disorder Hypersomnia Related to ... [brdicnte tile Axis lor Axis II Disorder] Hypoactive Sexual Desire Disorder Hypochondriasis Identity Problem Impulse-Control Disorder NOS Inhalant Abuse Dependence -Induced Anxiety Disorder -Induced Mood Disorder -Induced Persisting Dementia -Induced Psychotic Disorder With Delusions With HaUucinations Intoxication Intoxication Delirium -Related Disorder NOS Insomnia Related to ... {Ind ica te tile Axis I or Axis II Disorder} Intermittent Explosive Disorder Kleptomania Learning Disorder NOS Major Depressive Disorder, Recurrent In Full Remission In Partial Remission Mild Moderate Severe Without Psychotic Fea tures Severe With Psychotic Features Unspecified Major Depressive Disorder, Single Episod~ In Full Remission In Partial Remission Mild
Alphabetica l listing of OSM-IV-TR Diag noses and Codes 296.22 296.23 296.24 296.20 608.89 302.72 607.84 608.89 302.74 V65.2 315.1 333.90 333.1 293.9 319 317 315.32 318.0 293.83 296.90 301.81 347 V61.21 995.52 Moderate Severe Without Psychotic Features Severe With Ps}'chotic Features Unspecified Male Dyspareunia Due to ... {Indicate the General Medical Condition} Male Erectile Disorder Male Erectile Disorder Due to . .. [Indicate the General Medical Condition} Male Hypoactive Sexual Desire Disorder Due to ... [Indicate the General
292.84
Medical Condition] Male Orgasmic Disorder Malingering Mathematics Disorder Medication-Induced Movement Di sorder NOS Postural Tremor Mental Disorder NOS Due to ... [Indicate ti,e General Medical Condition} Mental Retardation, Severity Unspecified Mild Mental Retardation Mixed Receptive-Expressive Language Disorder Moderate Mental Retarda tion Mood Disorder Due to ... [Indicate tile General Medical Condition) Mood Disorder NOS Narcissistic Personality Disorder Narcolepsy Neglect of Child Neglect of Child (if focus of attention is on victim) Neuroleptic-Induced Acute Akathisia Acute Dystonia Parkinsonism Tardive Dyskinesia Neuroleptic Malignant Syndrome Nicotine Dependence -Related Disorder NOS Withdrawal ightmare Disorder No Diagnosis on Axis II No Diagnosis or Condition on Axis I Noncompliance With Treatment Obsessive-Compulsive Disorder Obsessive-Compulsive Personality Disorder Occupational Problem Opioid Abuse Depen dence -Induced Mood Disorder
/ 852
Ap pe ndix E
292.11 292.12 292.89 292.89 292.89 292.81 292.9 292.0 313.81 625.8
-Induced Psychotic Disorder With Delusions With HaUucinations -Induced Sexual Dysfunction -Induced Sleep Disorder Intoxication Intoxication Delirium -Related Disorder OS Withdrawal Oppositional Defiant Disorder Oth er Female Sexua l Dysfunction Due to ... [Indicat e the General Medical
ConditiOIl J
608.89 Other MaJe Sexual Dysfun ction Due to .. . 11lldicate fi,e General Medical
COlldition1
305.90 304.90 292.89 292.81 292.84 292.83 292.82
Other (or Unknown ) Subs tance Abuse Dependence - Induced Anxiety Disorder -Induced Delirium -Induced Mood Disorder - In duced Persis ting Amnes tic Disord er -Induced Persisting Dementia -Induced Psychotic Disorder With Delusions With H allucinations - Induced Sexu al Dysfunction - Induced Sleep Disorder In toxication -Related Disorder NOS Withdrawal Pain Disorder Associa ted With Both Psych ologica l Factors and a General Medical Condition Associated With Psychologica l Factors Panic Disorder With Agoraphobia Without Agoraphobia Paranoid Personality Disorder Paraphilia NOS Parasonmia NOS Parent-Child Relational Problem Partner Relational Problem Pa thological Gambling Pedophilia Personality C hange Due to ... {Indicate tile Gel/emf Medicaf COlldition} Personality Disorder NOS Pervasive Developmen tal Disorder NOS
302.9
307.47 V61.20 V61.10 312.31 302.2 310.1 301.9 299.80
853
V62.89 Phase of Life Problem Phencyclidine (or Phencyclidine-Like) 305.90 Abuse 304.60 Dependence 292.89 - Induced Anxiety Disorder 292.84 - Induced Mood Disorder -Induced Psychotic Disorder 292.11 With Delusions 292.12 With Hallucinations 292.89 Intoxication Intoxication Delirium 292.81 292.9 -Related Disorder NOS 315.39 Phonological Disorder V6 1.12 Physical Abuse of Adult (if by partner) V62.83 Physical Abuse of Adult (if by person other than partner) 995.81 Ph)'sical Abuse of Adult (iffocus of attention is all victim) V61.21 Physica l Abuse o f Child 995.54 Physical Abuse of Child (iffoclls of attention is all victim) 307.52 Pica 304.80 Polysubs tance Dependence 309.81 Posttraumatic Stress Disorder 302.75 Premature Ejaculation 307.44 Primary H ypersomnia 307.42 Primary Insomnia 318.2 Profound Mental Retardation Psychological Factor Affecting Medical Condition 316 Psychotic Disorder Due to .. . [JlIdicate tile Gel/ernl Medical CO Jlditioll/ 293.81 With Delusions 293.82 With Hallucinations 298.9 Psychotic Disorder NOS 312.33 Pyromania 313.89 Reactive Attachment Disorder of Infancy or Early Childhood 315.00 Reading Disorder V62.81 RelationaJ Problem NOS V61.9 Relational Problem Rela ted to a Mental Disorder or General Medical Condition V62.89 Religious or Spiritual Problem 299.80 Rett's Di sorder 307.53 Rumination Disorder 295.70 Schizoaffective Disord er 301.20 Schizoid Personality Disorder Schizophrenia 295.20 Catatonic Type 295.10 Disorganized T}'Pe Para noid Type 295.30 295.60 Residual Type 295.90 Undifferentia ted Type
854
295.40 Schizophreniform Disorder 301.22 Schizotypal Personality Disorder Sedative, Hypnotic, or Anxiolytic Abuse 305.40 304.10 Dependence -Induced Anxiety Disorder 292.89
292.84 292.83 292.82 292.11 292.12 292.89 292.89 292.89 292.81 292.9 292.0 292.81 313.23 309. 21 318.1 V61.12 V62.83
-Induced Mood Disorder -Induced Persisting Amnestic Disorder -Induced Persisting Dementia -Induced Psychotic Disorder With Delusions With Hallucinations -Induced Sexual Dysfunction -Induced Sleep Disorder Intoxication Intoxication Delirium -Related Disorder NOS Withdrawal Withdrawal Delirium Selective Mutism Separation Anxiety Disorder Severe Mental Retardation Sexual Abuse of Adult (if by partner) Sexual Abuse of Adult (if by person other than partner) Sexual Abuse of Adult (if foclls of attention is all victim) Sexual Abuse of Child Sexual Abuse of Child (if foclls of attelltioll is 011 victim) Sexual A version Disorder Sexual Disorder NOS Sexual Dysfunction NOS Sexual Masochism Sexual Sadism Shared Psychotic Disorder Sibling Relational Problem Sleep Disorder Due to ... [Illdicate file Gel/eral M edical COllditioll1 Hypersomnia Type Insomnia Type Mixed Type Parasomnia Type Sleep Terror Disorder Sleepwalking Disorder Social Phobia Somatization Di sorder Somatoforrn Disorder NOS Specific Phobia Stereotypic Movement Disorder Stuttering
Appendix E
995.83
V61.21
995.53
302.79 302.9 302.70 302.83 302.84 297.3 V61.8 780.54
780.52 780.59
780.59 307.46 307.46 300.23
Appendix E
Alphabetical Listing of DSM-IV-TR Diagnoses and Codes 307.20 307.23 307.21 302.3 312.39 300.82 300.9 306.51 290.40 290.41 290.42 290.43 302.82 Tic Disorder NOS Tourette's Disorder Transient Tic Disorder Transvestic Fetishism Trichotillomania Undifferentiated Somatoform Disorder Unspecified Mental Disorder (nonpsychotic) Vaginismus (Not Due to a General Medical Condition) Vascular Dementia Uncomplicated With Delirium With Delusions With Depressed Mood Voyeurism
855 1
~r)
, Co"ditio,,]
Appendix F
same code numbers. These are indicated in this list by brackets. NOS = Not Otherwise Specified.
290.40 290.41 290.42 290.43 291.0 291.0 291.1 291. 2 291.3
291.5
291.81 291.89
29 1.89
291.89 291.89
291.9
292 .0
292.0 292.0 292.0 292.0 292.0 292.11 292.11 292. 11 292.11 292.11 292.11
Vascular Dementia, Un complicated Vascular Dementia, With Delirium Vascular Dementia, With Delusions Vascular Dementia, With Depressed Mood Akohol lntoxication Delirium Alcohol Withdrawal Delirium Alcohol-Induced Pers is ting Amnestic Disorder Alcohol-Ind uced Persisting Dementia Alcohol-Induced Psychotic Disorder, ''''ith Hallucinations Alcohol-Induced Psychotic Disorder, With Delusions Alcohol Withdrawal Alcohol-Induced Anxiety Disorder Alcohol-Induced Mood Disorder Alcohol Induced Sexual Dysfunction Alcohollnduced Sleep Disorder Alcohol-Related Disorder NOS Amphetamine Withdrawal Cocaine Withdrawal icotine Withdrawal Opioid Withdrawal Other (or Unknown) Substance Withdrawal Sedative, Hypnotic, or Anxiolytic Withdrawal Amphetamine--lnduced Psychotic Disorder, With Delusions Cannabislnduced Psychotic Disorder, With Delusions Cocaine!Jlduced Psychotic Disorder, With Del usions HallucinogenInduced Psychotic Disorder, With Delusions Inha lant-Induced Psychotic Di sorder, With Delusions Opioid-Induced Psychotic Disorder, With Delusions
857
1858
Appendix F
[
[
292.11 Other (or Unknown) Substance-Induced Psychotic Disorder, With Delusions 292.11 Phencyclidine-Induced Psychotic Disorder, With Delusions 292.11 Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder, With Delusions 292.12 Amphetamine-Induced Psychotic Disorder, With Hallucinations 292.12 Cannabis-Indu ced Psychotic Disorder, With Hallucinations 292.12 Cocaine-Induced Psychotic Disorder, With Hallucinations 292.12 Hallucinogen-Induced Psychotic Disorder, With Hallucinations 292.12 Inhalant-Induced Psycho tic Disorder, With Hallucinations 292.12 Opioid-Induced Psychotic Disorder, With Hallucinations 292.12 Other (or Unknown) Substance-Ind uced Psychotic Disorder, With Hallucinations 292.12 Phencyclidine-Induced Psychotic Disorder, With Hallucinations 292.12 Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder, With Hallucinations 292 .81 Amphetamine Intoxication Delirium 292.81 Cannabis Intoxication Delirium 292.81 Cocaine Intoxica tion Delirium 292.81 Hallucinogen Intoxication Delirium 292.81 Inhalant Intoxication Delirium 292.81 Opioid Intoxication Delirium 292.81 Other (or Unknown) Substance-Induced Delirium 292.81 Phencyclidine Intoxication Delirium 292.81 Seda tive, Hypnotic, or Anxiolytic Intoxica tion Delirium 292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium 292.82 Inhalant-Induced Persisting Dementia 292.82 Other (or Unknown) Substance-Induced Persisting Dementia 292.82 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia 292.83 Other (or Unknown) Substance-Induced Persisting Amnestic Disorder 292.83 Seda tive-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disord er 292.84 Amphetamine-Induced Mood Disorder 292.84 Cocaine-Induced Mood Di sorder 292.84 Hallucinogen-Induced Mood Disorder 292.84 Inhalant-Induced Mood Disorder 292.84 Opioid-lnduced Mood Disorder 292.84 Other (or Unknown) Substance-Induced Mood Disorder 292.84 Phencyclidine-Induced Mood Disorder 292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder 292.89 Amphetamine-Induced Anxiety Disorder 292.89 Amphetamine-Induced Sexual Dysfunction 292.89 Amphetamine-Induced Sleep Disorder 292.89 Amphetamine Intoxication 292.89 Caffeine-Induced Anxiety Disorder 292.89 Caffeine-Induced Sleep Disorder 292.89 Cannabis-Induced Anxiety Disorder 292.89 Cannabis Intoxication 292.89 Cocaine-Induced Anxiety Disorder
859
292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 192.89 292.89 292.89 292.89 292.89 292.89 - 292.89 - 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 - 292.9 293.0 293.81 293.82 293.83 293.84 293.89 293.9 294.0 294.10"
Cocaine-Induced Sexual Dysftmction Cocaine-Induced Sleep Disorder Cocaine Intoxication Hallucinogen-Induced Anxiety Disorder HallUcinogen Intoxica tion Hallucinogen Persisting Perception Disorder Inhalant-Induced Anxiety Disorder Inhalant Intoxication Opioid-Induced Sexual Dysfunction Opioid-Induced Sleep Disorder Opioid Intoxication . Other (or Unknown) Substance-Induced Anxiety Disorder Other (or Unknown) Substance-Induced Sexual Dysfunction Other (or Unknown) Substance-Induced Sleep Disorder Other (or Unknown) Substance Intoxication Phencyclidine-Induced Anxiety Disorder Phencycl idine Intoxication Sedative-, Hypnotic-, or Anxiolytic-lnduced Anxiety Disorder Sedative-, Hypnotic-, or Anxiolytic-Tnduced Sexual Dysfunction Sedative-, Hypn otic-, or Anxiolytic-Induced Sleep Disorder Sedative, Hypnotic, or Anxiolytic Intoxication Amphetamine-Related Disorder NOS Caffeine-Rela ted Disord er NOS Cannabis-Related Disorder NOS Cocaine-Related Disorder NOS Hallucinogen-Related Disorder as Inhalant-Related Disorder NOS Nicotine-Related Disord er NOS Opioid-Related Disorder 'as Other (or Unknown) Substance-Related Disorder NOS Phencyclidine-Related Disorder as Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS Delirium Due to .. . l1/1dicate tile General Medical Conditioll) Psychotic Disorder Due to .. . IIJ/dicate Ille Gelleral Medical COllditioll}, \<\' ith Delusions Psychotic Disorder Due to . .. {I"dicate tIJe General iVledical COl/ditIOIl/, With Ha llucinations Mood Disorder Due to ... [Ilidicate tile General Medical COllditiOIl] Anxiety Disorder Due to ... {Indicate the General Medical Condiliolll Catatonic Disorder Due to . .. [Indicate the Geueml Medical Conditionl Mental Disorder NOS Due to ... [Indicate tile General Medical COllditionl Anmestic Disorder Due to ... [Judicate the Geueral M edical Condition] Dementia Due to ... /lndicate tile Gelleral Medical COlldition/, Without Behaviora l Disturbance
1 860
Appendix F
c::
294.10" Dementia of the Alzheimer's Type, With Ea rly Onset, Without Behavioral Dis turbance 294.10" Dementia of the Alzheimer's Type, With La te Onset, Without Behavioral Disturbance 294.11" Dementia Due to ... (lIldicate tile General Med ical Condition], With Behavioral Disturbance 294.11 Dementia of the Alzheimer's Type, With Early Onset, With Behavioral Disturbance 294.1 1 Dementia of the Alzheimer's Type, Wi th Late Onset, With Behavioral Dis turbance 294.8 Amnestic Disorder OS
Dementia NOS Cognitive Disorder NOS Schizophrenia, Disorganized Type Schizophrenia, Cata tonic Type Schizophrenia, Paranoid Type Schizophreniform Disord er Schizophrenia, Residual Type
Schizoaffective Disorder Schizophrenia, Un d ifferentiated Type Bipolar r Disorder, Single Manic Episode, Unspecified Bipolar I Disorder, Single Manic Episode, MUd Bipolar I Disorder, Single Manic Episode, Modera te Bipolar I Disorder, Single Manic Episode. Severe Without Psychotic Features Bipolar I Disorder, Single Manic Ep isode. Severe With Psychotic Features Bipolar I Disorder, Single Manic Episode, In Partial Remission Bipolar I Disorder, Single Manic Episode, In Full Remission Major Depressive Disord er, Single Episode, Unspecified Major Depressive Disorder. Single Episode, Mi ld Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder, Single Episode, Severe Without Psycho tic Features Major Dep ressive Disorder, Single Episode, Severe With Psychotic Features Major Depressive Disorder, Single Episode, In Partial Remission Major Depressive Disord er, Single Episode, In Full Remission Major Depressive Disorder. Recurrent, Unspecified Major Depressive Disord er, Recurrent, Mild Major Depressive Disorder. Recurrent, Moderate Major Depressive Disorder, Recurrent, Severe Without Psychotic Features Major Depressi\'e Disorder, Recurrent, Severe With Psychotic Fearures Major Depressive Disord er, Recurrent, In Partial Remission Major Dep ressive Disorder, Recurrent, In Full Remission Bipolar I Disorder, Most Recent Episode Hypomanic Bipolar I Disorder, Most Recent Episode Manic, Unspecified Bipolar I Disorder, Most Recent Episode Manic, Mild
296.24 296.25 296.26 296.30 296.31 296.32 296.33 296.34 296.35 296.36 296.40 296.40 296.41
,
Numer ical List ing of OSM-IV-TR Diagnoses and Codes
861
296.42 Bipolar I Disorder, Most Recent Episod e Manic, Moderate 296.4.3 Bip olar I Disord er, Mos t Recent Episode Manic, Severe Witho ut Psychotic Featu res 296.44 Bipolar 1 Disorder, Mos t Recent Episode Manic, Severe With Psychotic Fearures 296.45 Bipolar I Disorder, Most Recent Episode Man ic, In Partial Remission 296.46 Bipolar I Disord er, Most Recent Episode Man ic, In Full Remission 296.50 Bipolar I Disorder, Most Recent Episode Depressed, Unspedfied 296.51 Bipolar J Disorder, Most Recent Episode Depressed, Mild 296.52 Bipolar I Disorder, Most Recent Episod e Depressed, Modera te 296.53 Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psycho tic Features 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psych otic Fea tures 296.55 Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission 296.56 Bipolar I Disord er, Most Recent Episode Depressed, In Full Remission 296.60 Bipolar I Disorder, Most Recent Episode i\fu:ed, Unspecifi ed 296.61 Bi polar I Disorder, Most Recent Episode Mixed, Mild 296.62 Bipolar I Disorder, Most Recent Episode Mixed, Modera te 296.63 Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Fea tu res 296.64 Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features 296.65 Bipolar I Disorder, Mosl Recent Episode Mixed, In Partial Rem ission 296.66 Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission 296.7 Bipolar I Disorder, Most Recent Episode Unsp ecified 296.80 Bipolar Diso rder N OS 296.89 Bipolar II Disord er 296.90 Mood Disorder 'OS 297.1 Delu sional Disorder 297.3 Shared Psychotic Disorder 298.8 Brief Psychotic Disorder 298.9 Psychotic Disorder NOS 299.00 Autistic Diso rder 299. 10 Childhood Disintegrative Disorder 299.80 Asp erger's Disorder 299.80 Pervasive Developmental Disorder NOS 299.80 Rett's Disorder 300.00 Anxiety Disorder OS 300.01 Panic Disorder Withou t Agoraphobia 300.02 Generalized Anx iety Disorder 300.11 Conversion Disord er 300.12 Dissociative Amnesia 300.13 Dissociative Fug ue 300.14 Dissociative Identity Disorder 300.15 Dissociative Disorder N OS 300.16 Factitious Disord er With Predom inantly Psychological Signs and Symptoms
1862
Appendix F
300.19 Facti tious Disorder NOS 300.19 Facti tious Disord er With Combined Psychological and Physical Signs and
Symptoms
300.19 300.21 300.22 300.23 300.29 300.3 300.4300.6 300.7 300.7 300.81 300.82 300.82 300.9 301.0 301.1 3 301.20 301.22 301.4 301.50 301.6 301.7 301.81 301.82 301.83 301.9 302.2 302.3 302.4 302.6 302.6 302.70 302.71 302.72 302.72 302.73 302.74 302.75 302.76 302.79 302.81 302.82 302.83 302.84
c:::
[
Facti tious Disorder With Predominantly Physical Signs and Sym ptoms Panic Disorder With Agoraphobia Agoraphobia '''' ithout History of Panic Disord er Social Phobia Specific Phob ia Obsessive-Compulsive Disorder Dysthym ic Disorder Depersonalization Disorder Body Dysmorphic Disorder H yp ochondriasis Somatization Diso rder Somatoform Disord er NOS Undiffere ntiated Somatoform Disorder Unspeci fied Mental Disorder (nonpsychotic) Paranoid Personality Disorder
c:::
863 1
Alcohol Dependence Opioid Dependence Seda tive, H}' pnotic, or Anxiolytic Dependence Cocaine Depend ence Cannabis Dependence Amphetamine Dependence Ha llUCinogen Depend ence Inhalant Dependence Phencyclidine Dependence Po lysubstance Dependence Other (or Unknown) Substance Dependence Alcohol Abuse Nicotine Dependence Cannabis Abuse Hallucinogen Abuse Sedative, Hypnotic, or Anxiolytic Abuse
O pioid Abuse Cocaine Abuse
307.23
307.3
[ [
307.42 307.42 307.44 307.44 307.45 307.46 307.46 307.47 307.47 307.47 307.50
Amphetamine Abuse Caffeine Intoxication Inhalant Abuse Other (or Unknown) Substance Abuse Phencyclidine Abuse Vaginismus (Not Due to a General Medica l Condition) Stuttering Anorexia Nervosa Tic Disorder NOS Transien t Tic Disorder Chronic Motor o r Vocal Tic Disorder Tourette's Disorder Stereotypic Movement Disorder Insomnia Related to .. . /Illdica te tile Axis lor Axis II Disorderl Primary lnsomnia Hyp ersomnia Related to . . . [Illdicate tile Axis lor Axis II Disorderl Primary Hypersomnia Circadian Rhythm Sleep Disorder Sleep Terror Disord er Sleep walking Disorder Dyssomnia NOS N ightmare Disorder Parasomnia NOS Eating Diso rder NOS
864
Appendix F
307.51 Bulimja Nervosa 307.52 Pica 307.53 Rumination Disorder 307.59 Feeding Disorder of Infancy or Earl}' Childhood 307.6 Enuresis (Not Due to a General Medical Condition) 307.7 Encopresis, Without Constipation and Overflow Incontinence 307.80 Pain Disorder Associated With Psycho logical Factors 307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition 307.9 Communication Disorder 'OS 308.3 Acute Stress Disorder 309.0 Adjustment Disorder With Depressed Mood 309.21 Separation Anxiety Disorder 309.24 Adjustment Disorder With Anxiety 309.28 Adjustment Disorder With Mixed Anxiety and Depressed Mood 309.3 Adjustment Disorder With Disturbance of Conduct 309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct 309.81 Posttraumatic Stress Disorder 309.9 Adjustment Disorder Unspecified 310.1 Personality Change Due to ... [Jndicate tile General Medical COllditioll/ Depressive Disorder NOS 311 312.30 Impulse-Control Disorder NOS 312.31 Pathological Gambling 312.32 Kleptomania 312.33 Pyromania 312.34 Intermittent Explosive Disorder 312.39 Trichotillomania 312.81 Conduct Disorder, Childhood-Onset Type 312.82 Conduct Disorder, Adolescent-Onset Type 312.89 Conduct Disorder, Unspecified Onset 312.9 Disruptive Behavior Disorder NOS 313.23 Selective Mutism 313.81 Oppositional Defiant Disorder 313.82 Iden tity Problem 313.89 Reactive Attachment Disorder of Infancy or Early Childhood 313.9 Disorder of Infancy, Childhood, or Adolescence NOS 314.00 Attention-Deficit/ Hyperactivity Disorder, Predominantly Inattentive Typ 314.01 Attention-Deficit/ Hyperactivity Disorder, Combined Type 314.01 Attention-Deficit/ Hyperactivity Disorder, Predominantly HyperactiveImpulsive Type 314.9 Attenti on-Deficit/ Hyperacti vity Disorder NOS 315.00 Reading Disorder 315.1 Mathematics Disorder 315.2 Disorder of Vhitten Expression 315.31 Expressive Language Disorder 315.32 Mixed Receptive-Expressive Language Disorder 315.39 Phonological Disorder
865 1
315.4
315.9 316
333.1 333.7 333.82 333.90 333.92 333.99 347 607.84 608.89 608.89 608.89
625.0 625.8 6258 780.09 780.52
Narcolepsy
Male Erectile Disorder Due to ... {Judicate the Gel/ernl MediC/if COllditioll} Male Dyspareunia Due to ... (Indicate the Genernl Medical Condition] Male Hy poactive Sexua l Desire Disorder Due to ... [Indicate the Medical Condition] O ther Male Sexual Dys fun ction D ue to . . . [Indicate the Gel/ernl Medical Condition] Fe male Dyspareunia Due to ... [II/dicate Il,e Gel/ernl Medical COl/ditiol/j Fe m ale H ypoacti ve Sexual Desire Disorder Due to ... [Ill dicate the Gel/ernl Medical Condition] Other Female Sexu al Dysfunction D ue to ... [II/dicate tlie Gel/ernl Medical Condition) Delirium NOS Sleep Disorder Due to ... {Indicate the General Medical COl/ditio,,/. In somnia Type Sleep Disorder Due to . . . {II/dicate the Gmeral Medical COl/ditiol/], H ypersomnia Type Breathing-Related Sleep Disorder Sleep Disorder Due 10 ... [Indicate the Gel/emf Medical COl/dition], Mixed Type Sleep Disorder Due to .. . /fndicate the Gel/eraf Medical Condition], Parasomnia T)'P e AgeRelaled Cog nitive Decline Encopresis, With Constipation and Overflow Incontinence Diagnosis Deferred on Axis U Diagnosis or Condition Deferred on Axis I Adverse Effects of M edica tion NOS Neglect o f Child (ifjoClls oj attentiol/ is 011 victim) Sexual Abuse of Child (iffoclls oj a/fellfion is 01/ victim) Physical Abuse of Child (if joclls oj attel/tion is 011 victim) Physical Ab use of Adult (if joClls oj attentioll is on victim) Sexual Abuse of Adult (ifjocus oj atten tioll is 011 victim)
r
I
780.54
780.59 780.59 780.59 780.9 787.6 799.9
799.9 995.2
995.52
995.53
995.54 995.8 1 995.83
866
V15.81 \161.10 V61.12 V61.12 V61.20 V6 1.21 V61.21
V61.21
Appendix F
V61.8 V61.9
\162.2 V62.3 V62.4 V62.8J
V62.8 7
[
[
V62.83 V62.83 V62.89 \162.89 \/62.89 \165.2 V71 .01 V71.02 V71.09 V7J.09
'oncompliance ''''ith Treatment Partner Relational Problem Physical Abuse of Adult (if by partner) Sexual Abuse of Adult (if by pa rtner) Parent-Child Relational Problem Neglect of Child Physical Abuse of Child Sexual Abuse of Child Sibling Relational Problem Relational Problem Related to a Mental Disorder or General Med ical Condition Occupational Problem Academic Problem Accultura tion Problem Relational Problem NOS Bereavement Physical Abuse of Adult (if by person other than partner) Sexual Abuse of Adult (if by person other than partner) Borderline Intellectual Functioning Phase of Life Problem Religious or Spiritual Problem Malingering Adult Antisocial Behavior Child or Adolescent Antisocial Behavior No Diagnosis on Axis U No Diagnosis or Condition on Axis I
Appendix G
ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders
Updated to include
IC0-9-C~'1
T he official coding system in use as of the publication of OSM-IV is the Il/tema/jOllnl ClassificatioJl a/Diseases, 9th Revision, CUnical Modification OCD-9-CM). This appendix
contains h\'o sections that are provided to facilitate ICD-9-CM coding: 1) codes for selected general medical conditions, and 2) codes fo r medication-induced disorders.
867
868
Appendix G
eases: Alphabetic Index (Volume 2). These documents are updated every October and arc published by the U.s. Departmen t of H ealth and Human Servi ces. They are available from the Superintendent of Documents, U.S. Government Printing Office, as well as from a number o f private publishers. Note: An asterisk e) following the ICD-9-CM code indicates that greater sp ecificity (e.g., a specific complication or anatomical site) is available. Refer to the ICO-9-0." Diseases: Tabular Lis t (Volume 1) entry for that code for add itional information.
358.0
350.1
Myasthenia gravis
Neuralgia, trigeminal
Neuropathy, peripheral autonomic Pain, face, atypical Pa lsy, BeU's Pa lsy, cerebral
Palsy, p seudobulbar Panencephalitis, s ubacute sclerosing Paresis, general Parkinson's disease, primary Pick 's disease 357.9+ POlyneuropathy 348.2 Pseudotumor cerebri (benign intracranial hypertension) 335.20 Sclerosis, amyotrophic la teral 340 Sclerosis, multiple (MS) 345.3 Status, grand mal 345.2 Status, petit mal 345.70 Status, temporal lobe 433.1 Stenosis, carotid artery, without cerebral infarction 436 Stroke (CVA) 330.1 Tay-Sachs d isease 333.1 Tremor, benign essen tial
1870
428.0~
Appendix G
403.91 Hypertensive renal disease with failure 403.90* Hypertensive renal disease without failure
458.0 410.90" 424.0 424.0 394.0 423.9
451 . 9~
Hypotension, orthos tatic Infarction , myocardial, acute Mitral valve insufficiency (noruheumatic) Mitral valve prolapse Mitral valve stenosis (rheumatic) Pericarditis
ICD-9-CM Codes f or Se lected General Med ical Cond itions and Medication-Induced Disorders
871
Pneumonia, mycoplasma Pneumonia, unspecified bacterial Pneumonia, pneumococcal Pneumonia, pneumocystis Pneumonia, streptococcus Pneumonia , uns pecified o rganism Pneumonia, viral Pneumothorax, spontaneous Pneumo thora x, traumatic Tuberculosis, pulmonary
Neoplasms
ICD-9-CM diagnostic codes for neoplasms are classified in the table of neoplasms in the ICO-9-CM Alphabetic Index (Volume 2) according to site and degree of malig nancy (primary, secondary, in situ, benign, uncertain, unspeCified). Note: For patients with a personal history o f malignant neoplasms that have been surgically removed or eradicated by chemotherapy or radiation therapy, codes VI0.O-VI0.9 should be used; for specific sites, refer to the Alphabetic Index (Volume 2) of ICD-9-CM under " History (personal) of, malignant neoplasm. " Listed below are some of the most common codes assigned for neoplasms. 228.02 201.90" 176.9" 208.01" 208.00" 20S.11" 208.10" 200.10 225.2 203.01 203.00 225.0 211.4 195.2 194.0 188.9" 170.9 198.5 191.9" 198.3 174.9" 175.9" 162.9" 180.9" Hemangioma of brain Hodgkin's disease Kaposi's sarcoma Leukemia, acute, in remission Leukemia, acute Leukemia, chronic, in remission Leukemia, chronic Lymphosarcoma Meningioma (cerebral) ~'lultiple myeloma, in remission Multiple myeloma Neoplasm, benign, of brain eopiasm, benign, of colon Neoplasm, malignant, abdominal cav ity, primary Neoplasm, malignant, adrenal gland, primary Neoplasm, malignaJlt, bladder, primary Neoplasm, malignant, bone, primary Neoplasm, malignant, bone, secondary Neoplasm, malignant, brain, primary Neoplasm, malignant, brain, secondary Neoplasm, malignant, breast. female, primary eoplasm, malignant, breast, male, primary Neoplasm, malignant, bronchus, p rimary Neoplasm, malignant, cervix, primary
872
153.9+ Neoplasm, malignan t, colon, primary 197.5 Neoplasm, malignant, colon, secondary 171.9+ Neoplasm, malignant, connective tissue, primary
Appendix G
189.0 Neoplasm, malignant, kidney, primary 155.0 eopiasm, malignant, liver, primary 197.7 Neoplasm, malignan t, liver, secondary
162.9" Neoplasm. malignant, lung, primary 197.0 T eoplasm, malignant, lung, secondary
183.0" Neoplasm, ma lignant, ovary, primary 157.9+ Neoplasm, malignant, pancreas, primary
185 154.1 173.9 151.9 186.9* 193 179 237.70 227.0 194.0 238.4 Neoplasm, maHgnant, prostate, primary Neoplasm, maUgnant, rectum, p rimary Neoplasm, malignant, skin, primary T eoplasm, malignant, stomach, site unspecified, p rimary Neoplasm, malignant, testis, primary Neoplasm, malignant, thyroid, primary Neoplasm, malignant, uterus, primary Neurofibroma tosis Pheochromocytoma, benign Pheochromocytoma. malignant Polycythemia vera
Endocrin e Di seases
253.0 255.2 259.2 255.4 255.0 253.5 250.00 250.01* 253.2 241.9* 240.9 255.1 Acromegaly Adrenogenita l disorder Carcinoid syndrome Corticoadrenal insufficiency Cushing's syndrome Diabetes insipidus Diabetes mellitus, type II/ non-insulin-dependent Diabetes mellitus. type I/ insulin-dependent Dwarfism, pituitary Goiter. nontoxic nod ular Goiter, simple Hyperaldosteronism 252.0 Hyperpa rathyroid ism 252.1 Hypoparathyroidism 244.9 Hypothyroidism, acquired 243 Hy pothyroidism, congenital 256.9* Ovarian d ysfunction 253.2 Panhypopituitarism 259.0 Sexual development and puberty, delayed
ICD-9-CM Codes for Selected Genera l Medical Conditions and Med icat ion- Induced Disorders 259.1 257.9+ 245.9+ 242.9+ Sexual development and puberty, precocious Testicular d ysfun ction Thyroiditis Thyrotoxicosis
873 1
Nutrition al Diseases
265.0 269.3 266.2 269.3 260 262 261 278.00+ 265.2 266.0 264.9+ 266.1 266.2 267 268.9 269.1 269.0 Beriberi Calci um deficiency Folic acid deficiency Iodine deficiency Kwashiorkor Malnutrition, protein-caloric, severe Nutritional marasmus Obesity Pellagra (niacin deficiency) Riboflavin deficiency Vitamin A deficiency Vitamin B6 deficiency Vitamin B12 deficiency Vitamin C d eficiency Vitamin 0 deficiency Vitamin E deficiency Vitamin K deficiency
Metabolic Diseases
276.2 276.3 277.3 276.5 271.3 276.9+ 276.6 274.9+ 275.0 275.42 276.7 276.0 275.41 276.8 276.1 270.1 277.1 277.2 275.1
Acidosis Alkalosis Amyloidosis Depletion, volume (dehydration) Disaccharide malabsorption (lactose intolerance) Electrolyte imba lance Fluid overload / retention Gout Hemochromatosis Hypercalcemia Hyperkalemia Hypematremia Hypocalcemia Hypokalemia Hyponatremia Phenylketonuria (PKU) Porphyria Lesch-Nyhan syndrome Wilson 's disease
Appen d ix G
"
ICD-9CM Codes fo r Selected General Medica l Cond it ions and Medication -Induced Disorders
875
592.1
592.9~
595.9+ 625.3 617.9584.9" 585 403.91* 586218.9" 580.9" 600.0 628.9 606.9 627.9 626.9" 625.2 620.2 614.9" 607.3 618.9" 601.9" 593.3 598.9599.0
Calculus, ureter Calculus. urinary. unspecified Cystitis Dysmenorrhea Endometriosis Failure. renal, acute Failure. renal, chronic Failure, renal, hypertensive Failure, renal, unspecified Fibroid of uterus Glomerulonephritis, acute Hypertrophy, p rostatic, benign (BPH ) Infertili ty, fem ale infertility, male Menopa usal or postmenopausa l disorder lenstruation, disorder of, and abnorma l bleeding Mittelschmerz Ovarian cyst Pelvic inflammatory disease (PID) Priapism Prolapse, genital Prostatitis Stricture, ureteral Stricture, urethral Urinary tract infection (UTI)
Hematological Diseases
288.0 287.0 284.9" 281.2 283.9 283.11 280.9 283.10 283.19 281.0 282.60* 286.9" 288.3 282.4 287.5* Agranulocytosis Allergic purpura Anemia, aplastic Anemia, folate-deficiency Anemia, hemolytic, acquired Anemia, hemolytic-uremic syndrome Anemia, iron-deficiency Anemia, nonautoimmune hemolytic, unspecified Anem ia, other autoimmune hemolytic Anemia, pernicious Anemia, sickle-cell Coagulation d efects Eosinophilia Thalassemia Thrombocytopenia
1876
361.9 Detachment retina l 365.9 Glaucoma
377.30 379.50 377.00 369.9 Neuritis, optic Nystagmus Papilledema Visual loss
Appendix G
ICD-9-CM Codes fo r Selected General Med ical Co nd it io ns and Med ication-I nduced Disorders
877 1
Erythema multi forme 703.0 Ing rowing nail 70 1.4 Keloid scar 696.1 Pso riasis 707.0 Ulcer, d ecubitus 708.0 Urticaria, allerg ic
695.1
Eclampsia Hyperemesis gravidarum, m ild Hyperemesis grav ida rum, w ith metabolic d isturbance Pre-eclampsia, mild Pre-eclampsia, severe
Infecti o us Diseases
The foUow ing codes rep resen t ICD-9-CM diagnostic codes for infections from sp ecific organ isms . Trad itionaUy, cod es for organisms from the 041 ca tego ry are used as
1 878
006.9 Amebiasis 112.5 Cand idiasis, disseminated 11 2.4 Candidiasis, lung 112.0 Candidiasis, mouth 112.2 Candidiasis, other urogenital siles 112.3 Candidiasis, s kin and nails 112.9 Cand idiasis, uns pecified site 112.1 Candidiasis, vu lva and vagina 099.41 ClJlamydin tmeholl/ntis 001.9 C holera 1.83 Clostridiu/ll perfrigclIs 114.9 Coccidioidomycosis 078.1 Condyloma oculi/ina/III/! (viral warts) 079.2 Coxsackie virus 11 7.5 C ry ptococcosis 041 .4 Esdteric1lia coli (E. coli) 007.1 Giardiasis 098.r Gonorrhea 0-1 1.5 Hemophillls iI/fit/cliMe (H. injlllellZile) 070.1 Hepatitis, viral A 070.3" Hepatitis, viral B 070.51 Hepatitis, viral C 054.9'" Herpes simplex 053.9'" Herpes zoster 115.9~ Histoplasmosis 042 HIV infection (symptomatic) 036.9~ Infection, meningococcal 079.99 ~ Infection, viral, unspecified 487.1 Influenza, unspecified 487.0 Influenza, w ith pneumonia 041S Klebsiella pnelllllolliae 088.81 Lyme d isease 084 . 6~ Malaria 075 Mononucleosis 072.9' Mumps 1.81 Mycoplasllla 1.2 PneulIlococcus 041.6 Proteus 041.7 Pseudolllollas 071 Rabies 056.9~ Rubella 003.9'" Salmonella 135 Sarcoidosis 004.9~ Shigellosis
Appendix G
secondary codes (e.g., urinary tract infection due to Escheric1lin coli wou ld be coded as 599.0 [primary d iagnosis) and 041.4 [second ary diagnosis!).
ICD9CM Codes for Selected General Medi cal Cond itions and Medicationlnduced Disorders
0-l1.10" 041.00" 097.9" 082.9+
879
Staphylococcus StreptococCZls Syphilis Tickbome riketts iosis 130.9 T axaplasmasis Trichinosis 124 131.9" Trichomoniasis 002.0 Typhoid fe ver 081.9+ Typhus
Overdose
Add itional diagnostic codes for overdose/ poisoning can be located in the Alphabetic Index (Va lume 2) of ICD-9CM in the table of drugs and chemicals, listed alphabetiC.l lly by drug in the " Poisoning" col umn . Acetaminophen Adrenal cortical steroids Amyl/ butyl! nitrite 962.1 Andragens and anabolic steroids Anticholinergics 971 .1 969.0 Antidepressants 967.0 Barbitrnates 969,. Benzodiazepine-based tranquili zers 969.2 Butyrophenone-bascd tranquilizers 967.1 Chloral hydrate 968.5 Cocaine 967.5 Glutethimide 969.6 Hallucinogens / cannabis 962.3 Insulin and antidiabetic agents 967.4 Methaqualone 968.2 Nitrous oxide 970. 1 Opioid anta gonists 965.00 Opioids 967.2 Paraldehyde 968.3 Phencyclidine 969. 1 Phenothiazine-based tranquilizers 965. 1 Salicylates 970.9 Stimulan ts 962.7 Thyroid and thyroid deriva tives
965.4 962.0 972.4
/ 880
Appendix G
Persis ting Dementia, Substance-Induced Persisting Amnestic Disorder, SubstanceInduced Psychotic Disorder, Substance-Induced Mood Disorder, Substance-Induced Anxiety Disorder, Substance-Induced Sexual Dysfunction, Substance-Induced Sleep Disorder, and Medication-Induced Movement Disorders. When used in multiaxial evaluation, the E-codes should be coded on Axis I immediately following the related disorder. It should be noted that these E-codes do not apply to poisonings or to a
Anticonvulsants
E936.3 936.2 937.0 E936 .1 E936.3
Antiparkinsonian Medications
E936.4 941 .1 E933.0 E936.4 Amantadine Benztropine Diphenhydramine l -Dopa
Neuroleptic Medications
E939.2 Butyrophenone-based neuroleptics (e.g., haloperidol) E939.3 Other neuroleptics (e.g., thiothixene) E939.1 Phenothiazine-based neuroleptics (e.g., chlorpromazine)
ICD-9-CM Codes for Se lected Gene ral Medical Cond itions and Medication-Induced Disorders
881
Cardiovascular Medications
E942.0 E942.2 E942.1 E942.4 E942.3 E942.6 E942.5 Antiarrhy thmic medication (includes propranolol) Antilipemic and cholesterol-lowering medication Cardiac glycosid es (e.g., digitalis) Coronary vasodilators (e.g., nitrates) Ganglion-blocking agents (pentamethonium) O ther antihy pertensive agents (e.g., clonidine, guanethidine, reserpine) Other vasodilators (e .g., hydralazine)
Appe ndix G
944.4 Other diuretics {furosemid e, ethacrynic acid} 9-14.1 Purine deriva tive diuretics 9-14.7 Uric acid metabolis m drugs (probenecid)
Append ix H
of the publication of this text revision (in the latc s pring of 2000), the offi cial coding system in use in the United Sta tes is the Illtcmatiollal Ciassijicatioll of Diseases, Ninth Revision, CLinical Modification (ICD-9-CM). Throughout much of the world, the offi cial coding system is the Internatiollal Statistical Classification of Diseases fmd Relaled Healfll Problems, Ten th Revision oeD-1 0). The preparation o f DSM-IV h as been closely coordinated w ith the preparation of C hapter V, " Mental and Behavioura l Disorders," of IC D-IO (develop ed by the World Health Organization in anticipation of its even hlal implementation in the United States). Consultations between the Am erican Psychiatric Association and the World Health Organiza tion have resulted in OSM-IV codes and terms that are fully compatible with the codes and terms in the tabular index of lCD-to. To facilita te the use of DSM-IV internationally, presented below is the DSM-IV Classification w ith the lCD-t O codes.
As
of certain d isorders to indicate that the name of a specific mental disorder or general medical condition should be inserted when recording the name (e.g., FOS.O Delirium Due to Hypothyroidism ).
883
884
Appendix IATIENTION -DEF ICIT AND DISR UPTIVE BEHAVIOR DISORDERS (85) A tlen tion-Deficit/ Hyperactivity Disorde r (85) F90.0 Combined Type F98.8 Pred omina ntly Inattenti ve Typ e F90.0 Predominantly H yperactiveIm p ulsive Type F90.9 Attention-Defi cit / H yperacti \fity Disord er OS (93) F91.8 Cond uct Disorder (93) Specify type; Childhood-Onsel Type/
Adol escen tOnset Typ e
Diso rders Usually First Diagn osed in Infancy, Childhood, or Ado lescence (39)
MENTAL RETARDATION (41 ) No te: Tl! ese fire coded 0/1 Aris II. F70.9 Mild Men tal Retardation (43) F71 .9 Moderate Mental Retardation (43) F72.9 Severe Menial Re ta rda tion (43) F73.9 Profound Mental Re ta rd a tion (44) F79.9 Men tal Retardation, Severity Unspecified (44) LEARNING DISORDERS (49)
F91 .3 F91.9
Oppositional Defiant Disorder (I OO) Dis ruptive Be havior Disorder NOS (103)
FBl.O
Fa1.2
FBI .S
F81.9
INFA NCY OR EARLY CH ILDHOOD ( 103) F98.3 Pica (103) F98.2 Rumination Disorder (105) F98.2 Feeding Dis order of Infancy or Early Ch ild hood (107) TIC DISORDERS (108) F95.2 Tourette's Disorder (111) F95.1 Chronic Motor or Vocal Tic Disorder (1 14) F95.0 Transie nt Tic D isord er (115)
Specify if Single Episode/ Rerurrent
MOTOR SK ILLS DISORDER (S6) F82 Developmental Coordina tion Disord er (56) COMM UNICATION DISORDERS (58)
FaD.1
FSO.2
FaD.a F98.5 FSO.9
Mixed Receptive-Expressive Language Disorder (62) Phonological Di sorder (65) Stuttering (67) Communication Disorder NOS
(69)
F95.9
ELIMINATION DISORDERS (11 6) Entopresis (1 16) R15 With Constipation and Overflow Incontinence (also
F84.0 F84.2
F84.3 F84.5 F84.9
code G30.0 Alzheimer's Disease, Wit/I Early Onset, 011 Axis Ill)
(154) .00 Uncomplicated .01 With Delusions .03 With Depressed Mood
SptdfiJ if Wi th Beha \oiora i Oi5turbiUlce
F98.9
FOO.xx Dementia of the Alzheimer's Typ e, With Late Onset (also code C30.l Alzheimer's Disease, WitIE Late Onset, 01 1 Axis Ill) (154 ) .10 Uncomplicated .11 With Delusions .13 With Depressed Mood
SptdfiJ if With Beha\'ioral Distu rbance F01.xx Vascular Dementia (1 58)
.80
.81 .83
F02.4
F02.8
_ .-
_.-
F02.2
etiologies) (146)
F05.9 Delirium NOS (147) F02.1
886
F02 .8 Dem entia Due to .. . Illldicate the General MediCfl/ COllditionnot
Appendix'
listed above} (also code tile general mediCflI condition all Axis 111)
-"(1 67) Substance-Induced Pe rsisting Dem e ntia (refer to SlIbstallee-
-"-
(21~ '
Alcohol Use Disorders (213) FlO.2x Alcoh o l Dependencea (213) FlO.1Alcoh o l Abu se (214) Alcohol-Induced Disorders (2 14) FlO. DO Alcohol Intoxication (214) FlO.3 Alcoh ol W ithdraw al (215)
Sp!'cify if With Perceptual DisturbanCt'S
Mental Disorders Due to a General Medi cal Condition Not Elsewhere Classified ( 181)
F06.1
F09
Mental Disorder NOS Due to . . . Illldimte the General MediCflI Condition] (190)
FlO.03 A lco h o l Intoxication Delirium (143 ) FlO.4 Alcoh o l Withdrawal Delirium (143) F10]3 Alcohol-Induced Persisting Demen tia (168) FlO.6 Alcohol Ind uced Persisting Amnes tic Diso rde r (177) FlO.xx Alcohol-lnduced Psych otic Di sord e r (338) .51 W ith Delusions!,w .52 With H a llucinations tW F10.S Alcoh o l-Induced Mood Disorde r!'w (405)
DSM-IV Classification (Wi th ICD-1 0 Codes) FlO.8 FlO.8 FlO.8 FlO.9 Alcohol-Induced Anxiety Disorde r i ,\\' (479) Alcohol-Induced Sexual Dysfunctio n l (562) A lcohol -Induced Sleep Disorder I,W (655) Alcohol-Rela ted Disorder NOS (223) F1 5.8 F1 5.9 Caffeine-Induced Sleep Disorder' (655)
887
CANN AB IS-RELATED DISORDERS (234) Cannabis Use Diso rde rs (236) F12.2x Cannabis Depe ndencea (236) F12.1 Cannabis Abuse (236) Cannabis-Induced Diso rders (237) F12.00 Cannabis Intoxication (237) F12.04 Carmabis Intoxication, With Perceptual Di sturbances (237) F1 2.03 Cannabis Intoxication Delirium (143) F1 2.xx Cannabis-Induced Psychotic Disorder (338) .51 With Delu sions ' With Hallucinations' .52 Fl2.8 Cannabis-Induced Anxiety Disorder' (479) F12.9 Cannabis-Related Dis order
AMPHETAM INE (OR AMPHETAMINElI KE)- RELATED DISOR DERS (223) Amph e tamine Use Disorders (224) Fl5.2x Amphe tamine Dependencea
(224)
F15.1 Ampheta mine Abuse (225) Amphetamine-Induced Di sorders (2 26) F15.00 Amphetamine Intoxication (226) F15.0-I: Amphetamine Intoxication, Wi th Perceptual Disturbances (226) Fl5.3 Amphe tam in e \'Vithdrawal (227) Fl5.03 Amphetamine In toxica tio n Delirium (143) Fl5.xx Amphetamine-Induced Psychotic Disorder (338) With Delusions' .51 With H allucinations! .52 Fl5.8 Amphe tamine-Ind uced Mood Disorder!.\\' (405) F15.8 A mpheta m ine-lnd uced Anxiety Disorder' (479) F1 5.8 Amphe tamine-Induced Sexual Dysfunction i (562) F15.8 Amphetamine-Induced Sleep Disorderi,w (655) F15.9 Amphetamine-Related Disorder NOS (231)
NOS (241)
COCAI NE-RE LATED DISORDERS (241) Coca ine Use Diso rders (242) F14.2x Cocaine Dependencea (242) F14.1 Cocaine Abuse (243) Coca in e-Induced Disord ers (244) Fl4.00 Cocaine Intoxication (244) Fl4.1 Cocaine Intoxication, With Perceptua l Di Sh lrbances (244) F14.3 Cocaine \<\' ithdrawal (245) F14.03 Cocaine In toxica tion Delirium
(143)
F14.xx Cocaine-Induced Psychotic Disorder (338) With Delusions i .51 With Hall ucina tions' .52 F14.8 Cocaine-Ind uced Mood Disorder!'w (405) F14.8 Cocaine-Induced Anxiety Disorderi,w (479) F14.8 Cocaine-Ind uced Sexual Dysfunction ' (562)
CAF FEINE-RELATED DISORDERS (23 1) Caff eine-Ind uced Disorders (232) F15.00 Caffe ine Intoxication (232) F15.8 Caffeine-Induced Anxiety Disorder 1 (479)
888
FI4.S F14 .9 Cocaine-Induced Sleep
Dis order!'W (655)
Append ix H
F18.8 F1 8.9
F1 7.9
F11.04
f16 .9
Hallucinogen-Related Disorder
NOS (256)
Inhalant Use Diso rders (258) FIB.2x Inhalant Dep end ence~ (258) FI B.1 Inhalant A buse (259)
Inhalant-Induced Diso rders (259) FI 8.00 Inhalant Intoxication (259)
FIL8
F11.9
(271) Opioid Intoxication, With Pe rceph.lal Di sturbances (272) O pioid Withdrawal (272) Opioid Intoxication Delirium (143) Opioid-Induced Psychotic Disorder (338) With Delusions' With Ha llucinations' Opioid-Induced Mood Diso rder l (405) Opioid -Induced Sexua l Dysfunc tion' (562) Opioid-Induced Sleep Disorde~'w (655) Opioid-Related Disorder NOS (277)
F18.03 Inhalant Intoxication Delirium (143) F18.73 Inhalant-Induced Pers is ting Dementia (168) F1 8.xx Inhalant-Induced Psychotic Disorder (338) With Delu sions ' .51 With Hallucinations' .52 F18.8 Inhalant-Induced Mood Disorde~ (405)
FI9.1
DSMIV Classificat ion (With ICO l0 Codes) Phencyclidine+lnduced Diso rders (280)
FI9.00 Phencyclidine Intoxica tion (280) F19.D-1 Phencyclidine Intoxication, With Perceptual Disturbances
(280)
FI9.03 Phencyclidine Intoxication Delirium (143) F19.xx Phencyclidine-Induced Psychotic Disorder (338) .51 With Delusions' .52 With Hallucinations l F19.8 Phencyclidine-Induced Mood Disorder' (405) F19.8 Phencyclidine-Induced Anxiety Disorder' (479) F19.9 Phencyclidine-Related Disorder
NOS (283)
SEDATIVE-, HYPNOTIC-, OR ANXIOL YTIC-RELATED DISORDERS (284) Sedative, Hy pnotic, o r Anxio lytic Use Disorders (285)
F13.xx Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder (338) With Delusions',w With Halluci nationsl.\V F13.8 Sedative-, Hypnotic-, or Anxiolytic-lnduced Mood Disorderl,w (405) F13.8 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder'" (479) F13.8 Sedative-, Hypnotic-, or Anxiol},tic-lnduced Sexual Dysnmction' (562) F13.8 Sedati ve-, Hypnotic-, o r Anxio lytic-lnduced Sleep Disorderl,w (655) F13.9 Seda tive-, Hypnotic-, or Anxiolytic-Rela ted Disorder NOS (293)
F13.2x Sed ati ve, Hypnotic, or Anxiolylic Dependenceil (285) F13.1 Sedative, Hy pnotic, or Anxiolytic Abuse (286)
Sedative-, Hypnotic-, or Anxio lyticInduced Disorders (286)
POL YSUBST ANC E RELATED DISORDER (293) F1 9.2x Po lysubstance Dependenccil (293) OTHER (OR UNKNOWN) SU8STANCERELATED DISORDERS (294)
Other (or Un known) Substance Use Disorders (294)
F13.00 Sedative, Hypnotic, or An.xiolytic Intoxica tion (286) F13.3 Sedative, Hypnotic, or Anxiolytic Withdrawal (287)
Specify if: With Perceptual Disturbances
F19.2x Other (or Unknown) Substance Dependence" (192) F19.1 Other (or Unknow n) Substance Abu se (198)
Other (or Unknown) SubstanceInduced Disorders (295)
Fl 3.03 Sedative, Hypnotic, or Anxiolytic Intoxication Deli riu m (143) F1 3.4 Seda tive, Hypnotic, or Anxiolytic Withdrawal Deli rium (143) F1 3.73 Seda tive-, Hypnotic-, or Anxiolytic-Induced Persisti ng Dementia (168) F13.6 Seda tive-, Hypnotic-, or Anxiolytic+lnduced Persisting Amnestic Disorder (177)
F1 9.00 Other (or Unknow n) Substance Intoxication (199) F19.04 Other (or Unknown) Substance Intoxication, With Perceptual Disturbances (199) F19.3 Other (or Unknown) Substance Withdrawal (201)
Specify if: Wi th Perceptual Disturbances
/ 890
F19.03 Other (or Unknown) Substance-Induced Delirium
(code F19.4 if Ol/sct durillg witlldrawnl) (143) F19.73 Other (or Un known)
Appendix H
2", Episodic With Inle repisode Residual Symptoms (specify if. With Prominent Negali\'e Symptoms) 3 ", Episodic Wi th No Inlerepisode Residual Symptoms 0", Continuous (Sllify if With Prominent Negative Symptoms) 4 '" Single Episode In Partial Remission (spify if. With Prominent Negative Symptoms) 5 '" Single Episode In Full Remission 8 '" Other or Unspecified Pattern 9 '" l ess than 1 year since onset of initial acli\'e-phase symptoms
F1 9.6
F1 9.xx Other (or Unknown) Substance-Induced Psychotic Disorder (338) .51 With Delusions"\\' .52 With Hallucinations',w FJ9.8 Other (or Unknown ) Substa nce- Induced Mood
Disorder l,\\' (405)
F20.S
F1 9.8
F25.x .0
.1 F22.0
Schizoaffective Disorder (319) Bipolar Type Depressive Typ e Delusional Disorder (323)
Spmfy type: Erotomanic Trpe / Grandiose Type/ Jealous Trpe / Persecutory Type/ Somatic Type/ Mixed Type/ Unspecified Type
F19.8
F19.8
Other (or Unknown) Substance-Ind uced Sleep Disorder i ,\\' (655) Other (or Unknown) Substance-Related Disorder NOS (295)
.81 .80
F24 F06.x
F1 9.9
Schizophrenia and
.2 .0
'-
.Ox
.1x .2x
.3x .5x
Paranoid Type (313) Disorganized Type (314) Catatonic Type (315) Undifferen tiated Type (316) Residual Typ e (3 16)
(Indicate tile General Medical COllditioll] (334) With Delusions With Hallucinations Substance*lnduced Psychotic Disorder (refer to SubstallceRelated Disorders for sllbstnllcespecific codes) (338) Sl>I!Cify if With Onset Ouring
Intoxication / With Onset During Withdrawal
F29
Psychotic Disorder
OS (343)
,
Mood Diso rd ers (345)
Thefollowill g slJecijiers apply (jar crmellt or mosl recell l episode) to Mood Disorders as 1I01ed:
"Severity/ Psychotic / Remission 5pl'(:ifiers/ bChronic/ "With Catatonic Features/ dWith ~ I elancholic Features/~\'ith Atypical FeaturestfWith Postpartum Onset
Psychotic Features 2 = Severe With Psychotic Features 7 ", In Partial or Full Remission F31.6 F31.x Bipolar I D is order, Mos t Recent Episode M ixeda,.c,f,g,h,i (382) Bipolar I Dis o rde r, Most Recent Episode D e presseda,b,c,d,e,f,g.h,i
(382)
(392)
S,>fCify (cmullt or most rl'ulltrpi,<odd :
Hypomanic / ~pressed
2 = Se\'ere Without Psychotic Features 3 = Se\'ere With Psychotic Features Specify: },loodCongruent Psychotic Features/ Mood-Incongruent Psychotic Features 4 ", In Partial Remission :I = In Full Remission 9 '" Unspl'(:ified
F34.1 Dys th y mic Disorder (376) Spmfy if Earl)' Onset/ Late On5et Spify: With Atypical Features Depressive Dis order NOS (381)
F34.0 F31.9
Cyclothymic Disord e r (398) Bipolar Disorder N OS (400) F06.xx Mood Dis o rder Due to ...
F32.9
F39
Appendix H
So mato fo rm Di so rd e rs (4 85)
Panic Disorder Without Agoraphobia (433) F40.0! Panic Disorder With Agoraphobia (433) F40.00 Agoraphobia \Vithoul His tory of Panic Diso rder (441) F40.2 Specific Phobia (443)
F41.0
.5
.6
.7 F45,4
specify type: Ani mal Type / Natural Environ ment Type / Blood- InjectionInjury Type / Situ3tional T)'p e/ Othe r Type
F40.! F42.8
Somatiza tion Disorder (486) Und ifferentiated Somato form Disorder (490) Con version Disorder (492) With Motor Symp tom or Deficit W ith Seizures or Con vulsions W ith Senso ry Sym ptom or Deficit With Mixed Presentation Pain Disorder (498)
Spify Iypt; Associated With
Ps)'(:hological Factors/ Associa ted W Both Ps)'dlologi(:al Factors and a General Medi(:al Condition Spify if: Acute / Chronk
F43.!
Acute Stress Disord er (469) Generalized Anxiety Disorder (472) Anxiety Disorder Due to ... [llldicate Ow Gel/erat Medical COllditioll] (476)
S,,,,dfy if: With Genera lized Anxiety/ Wi th Pank Attacks/ With O bsessi\'e-Compulsive Symptoms
_.-
Substance-In duced Anxiety Disorder (refer to Subs/allceRelated Disorders for SlIhstallcespecific codes) (479)
Spify if Wi th Generali zed Anxiety /
With Panic Attacks/ With Obsessi"e-Comp ulsi \'e Symptoms/ With POObi(: Symptoms S;NCify if With Onset Du ring Intoxication / Wi th Onse t Du ring Wit hd rawal
F68.1
F68.!
F4! .9
Dissociati ve Di so rd e rs (519)
F44.0 F44.!
'50.S
Depersonalization Disorder
(530)
N4S.4
Male Hypoactive Sexual Desire Di sorder Due to .. . II I/dicate the General Med ical COllditioll1 (55S) Male Erectile Disord er Due to ... [I ndicate tire Gelleral
N94.8
NSO.8
Sexua l Desire Disorders (539) F52.0 H ypoactive Sexua l Desire Disorde r (539) FS2.10 Sexual Aversion Disorder (541) Sexual Arousal Disorders (543) FS2.2 Female Sexual A rousal Dis order (5-13) F52.2 Male Erectile Disorder (S.-l5) Orga smic Disorders (547) F52.3 Female Orgasmic Disorder
(547)
Sexual Dysfunction NOS (56S) Exhibitionis m (569) Fetis his m (569) Frotteurism (S70) Pedophilia (571)
Spify if Sexually Attracted to Males / Sexually Attracted to Females / Sexually Attracted to Both SIliCify if: Limited to Incest Spify type: uc1usi'"e Trpe/ Nonexdusi"e Type
PARAPHILIAS (566)
F52.3 F52.4
Sexual Pai n Disorde rs (554) F52.6 Dyspareu.nia (Not Due to a General Medical Conditio n)
(554)
F52.5
Sexua l Dysfunction Due t o a General Medical Condition (558) N94.8 Female Hy poactive Sexual Des ire Disorder Due to . ..
Sexual Masoch ism (572) Sexual Sadis m (573) Transvestic Fetishism (574) SJIify if: With Gender Dysphoria Voyeuris m (575) Paraphilia NOS (576)
1894
GENDER IDENTITY DISORD ERS (S76) F64.x Gender Identi ty Disorder (576) .2 in Children .0 in Adolescen ts or Adults
5ptr:ify if; Sexually Attracted to Ma lesl Sexually Attracted to Females/ Sexually Attracted to Both/ Sexually Attra cted to Neither
Appe nd ix H F51.3 FS1.8 Sleepw alking Disorder (639) Parasomnia NOS (644)
FSl.O
F64.9
F52.9
.8 .8
F50.2
Insom nia Type H yp ersomnia Type Parasomnia Type Mixed Type Su bstance-Induced Sleep Disorder (refer 10 Substance-
F50.9
F51.1
G47.4 G47.3
F51.2
F5 1.9
Intermittent Explosive D isorder (663) Kleptom ania (667) Pyromania (669) Pa thological Gambling (671) Trichotillomania (674) Impulse-Control D isorder NOS (677)
Para somn ias (630) F51.S N ightm are Disorder (631) F51.4 Sleep Terror D isorder (634)
F43.xx Adjustment Disorder (679) .20 With Depressed Mood .28 With Anxiety .22 With Mixed Anxiety and Depressed Mood .24 With Disturbance of Conduct With Mixed Dis turbance of .25 Emotions and Conduct Unspecified .9
Specify if: Acute / Chronic
F54
. .. {Specified PsyC//ological Factor] Affecting ... (Indicate Ole Genernl Medical CO/lditioll/ CllOose /lame based 011 lIuture of fac tors: (73 1)
Mental Disorder Affectin g Medical Condition Psychological Symptoms Affecting Med.ical Con dition Personality Traits or Coping Style Affectin g Medical Condition Maladap tive Health Behaviors Affecting Medical Condition Stress-Related Physiological Response Affecting Medical Cond.ition Other or Unspecified Psychological Factors Affecting Medical Condition
Note: These are coded 011 Axis II. F60.0 Paranoid Pers onality Disorder (690) F60.1 Schizoid Personality Dis order (694) Schizotypal Personality F21 Disorder (697) F60.2 Antisocial Persona lity Disorder (701) F60.31 Borderline Personality Di sorder (706) F60.4 His trionic Personality Disorder
F60.8
(711) Narcissistic Personality Disorder (71 4) Avoidant Personality Disorder
(71 8)
F60.6 F60.7
F60.5 F60.9
Dependent Personality Disorder (72 1) Obsessive-Compulsive Personality Dis order (725) Personality Disorder N OS (729)
Neuroleptic-Indu ced Parkinsonism (735) Neuroleptic Malignant Syndrome (735) Neuroleptic-Induced Acute Dystonia (735) Neuroleptic-Induced Acute Akathisia (735) Neuroleptic-Induced Tardive Dyskinesia (736) Medication-Induced Postural Tremor (736) Medication-Induced Movemen t Disorder NOS (736)
1896
OTHE R M ED ICATION-INDUCED DISO RDER (736) TBB.7 Adverse Effects of Medication NOS (736) RELATIONAL PROBLEM S (736) 263.7 Rela tional Proble m Related to a
A ppendix H
2 72.8
R4 1.8
R41.8
263.4
Z55.8
7.56.7 F93.8 Z71.8
Z60.3 Z60.0
263.0
F93.3 263.9
Problem (code 263.1 iffocu s of aUeIltioll is 011 child) (737) Partner Relational Problem
(737) Sibling Relationa l Problem (737) Rela tional Proble m NOS (737)
Child or Adolescent Antisocial Be havior (740) Borderline In tellectual Func tioning (740) Age-Rela ted Cognitive Decl ine (740) Bereavement (740) Academic Problem (741) Occupa tional Problem (741) Identity Problem (741 ) Religious o r Spiritual Problem (741) Acc ulturation Problem (741) Phase of Life P roblem (742)
PROBLEM S RELATED TO AB USE OR NE GLECT (73B) 174.1 Physical Abuse o f Child (738) 174.2 Sexual Abuse of Child (738) 174.0 Neglect of Chlld (738) T74.1 Physical Abuse of Adult (738) 174.2 Sexual Ab use of Adult (738)
ADDITIONAL COND ITIONS THAT MAY BE A FOC US OF CLINI CA L ATIENTION (739) Z91.1 Noncompliance With Trea tment (739) 276.5 Malingering (739) Z72.8 Adult Antisocial Behavior (740)
Unspeci fied Mental Disorder (nonpsychotic) (743) N o DiagnOSis or Condi tion on Axis I (743) Diagnos is o r Condition Deferred on Axis I (743) N o Diagnosis on Axis II (743) Diagnosis Deferred on Axis II (743)
Appendix I
his appendix is divided into hvo sections. The first section provides an outline for cultural formula tion designed to assist the clinician in systematically evaluating and reporting the impact of the individual's cultural context. The second is a glossary of culture-bolUld syndromes.
Cultural identity of the individual. Note the individual 's ethnic or cultural reference groups. For inulugrants and ethnic minorities, note separately the degree of involvement with both the culhue of origin and the host culture (where applicable). Also note language abilities, u se, and preference (including multilingualism). Cultural expl ana tions of the individual's illness. The following may be identified: the predominant idioms of dis tress through which symptoms or the need for social support are communicated (e.g., "nerves," possessing spirits, somatic complaints, inexplicable misfortune), the meaning and perceived severi ty of the individ ual's symp-
897
898
Appendix I
toms in relation to norms of the cultural reference group, any local illness category used by the indiv idual's family and community to identify the condition (see "Glossary of Culture-Bound Syndromes" below), the perceived causes or explanatory
models that the individual and the reference group use to explain the illness, and eurrent preferences for and pas t experiences with professional and popular sources of
care.
Cultural fa ctors related to psychosocial environment and levels of fun ctioning.
Cultural elements of the relationship behveen the individual and the clinician. Indica te d ifferences in culture and social statu s between the individual and the clinician and problems that these differences may cause in diagnosis and treatment (e.g., difficulty in communicating in the individual's first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, in determining whether a behavior is normative or pathologica l). Overall cultural assessment for diagnosis and care. The formulation concludes with a d iscussion o f how cultural considerations specifically innuence comprehensive diagnosis and care.
899
This glossary lists some of the best-studied culture-bo und syndromes and idioms of distress that may be encountered in clinica l practice in North America and includes relevant DSM-rv categories w hen data suggest that they should be considered in a diagnostic fonnulation. amok A dissociative episod e cha racterized by a period of brooding foUowed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects. The episode tends to be precipitated by a perceived slight or insult and seems to be prevalent only among males. The episode is often accompanied by persecu tory id eas, automatism, amnesia, exhaustion, and a return to premorbid state foDowing the episode. Some instances o f amok may occur during a brief psychotic episode or constitute the onset or an exacerbation of a ch ronic psychotic process. The origina l reports that used this term were from Malaysia . A similar behavior pattern is found in Laos, Philippines, Polynesia (cafard or cat/lUni), Papua New Guinea, and Puerto Rico (mal de pelea), and among the Navajo (i ich 'aa) . ataque de nervios An idiom of d istress principally reported. among Latinos from the Caribbean but recognized among many Latin American and La tin Mediterranean groups. Commonly reported sym p toms include uncontrol1able shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. Dissociative experiences, seizurelike o r fainting episodes, and suicida l gestures are prominent in some attacks but absent in others. A general feature of an ataque de nervios is a sense of being out of control. Ataques de nervios frequently occur as a dircct result o f a stressfu l event relating to the family (e.g., news of the death of a close relative, a separation or divorce from a spouse, conflicts with a spouse or children, or witnessing an accident involving a family member). People may experience amnesia for what occurred during the ataque de nerv ios, but they o therwise return rapidly to their usual level of functi oning. Although d escriptions o f some ataques d e nervios most closely fit w ith the DSM-rY description o f Panic Attacks, the association of most ataques w ith a precipitating event and the frequent absence of the hallmark symptoms of acute fear or apprehension distinguish them from Panic Disorder. Ataques span the range from no nnal expressions of d istress not associated with having a mental disorder to symptom presen tations associated with the diagnoses of Anxiety, Mood, Dissociative, or Somatoform Disorders. bilis and colera (also referred to as IIIll illa) The u nderlying cause of these syndromes is thought to be strongly experienced anger or rage. Anger is viewed among many Latino groups as a particularly powerful emotion that can have d irect effects on the body and can exacerbate existing symptoms. The major effect o f anger is to disturb core body balances (which are understood as a balance between hot and cold valences in the bod y and between the material and spiritual aspects of the body) . Symptoms can include acute nervous tension, headache, trembling, screaming, stomach disturbances, and, in more severe cases, Joss of consciousness. Chronic fa tigue may result from the acu te episode. boufee d eJirante A synd rome observed in West Afri ca and H aiti. This French term refers to a sudden outburst of agitated and aggressive behavior, marked confuSion,
Appendix I and psychomotor excitemen t. It may sometimes be accompanied by visua l and auditory hallucinations or paranoid id eation . These episodes may resemble an episode of Brief Psychotic Disorder. brain fag A term initially used in West Africa to refer to a condition experienced by high school or university students in response to the challenges of schooling. Symptoms include difficulties in concentrating, remembering, and thinking. Students often state that their brains are "fatig ued." Additional somatic symptoms are usually centered arolmd the head and neck and include pain, pressure or tightness, blurring of vision, heat, or burning. " Brain tiredness" or fatigue from " too much thinking" is an idiom of distress in many cultures, and resulting syndromes can resemble certain Anxiety, Depressive, and Somatoform Disorders. dhat A folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with the discharge of semen, whitish discolo ration of the u rine, and feelings of weakness and exhaustion . Similar to jirynn (India), SlIkm pmme/1/1 (Sri Lanka), and sllell-k'lIei (China). fa lli ng-ou t or blacking ou t These episodes occur primarily in southern United States and Ca ribbean groups. They are characterized by a sudden collapse, which sometimes occurs without w arning but sometimes is preceded by feelin gs of d izziness or "swinuning" in the head. The individual's eyes are usuaUy open but the person claims an inability to see. The person usua lly hears and understands what is occurring around him or her but feels powerless to move. This may correspond to a diagnosis of Conversion Disorder or a Dissociative Disorder. ghost sickness A preoccupation w ith death and the deceased (sometimes associated with witchcraft) frequ ently observed among members of many American Indian tribes. Various symptoms can be a ttributed to ghost sickness, including bad dreams, weakness, feelings of d anger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciou sness, confusion, feelings of futility, and a sense of suffocation . h wa-byu ng (also known as wool-hwa-b yung) A Korean folk syndrome literally translated into English as "anger syndrome" and attributed to the suppression of anger. The symptoms include insomnia, fatigue, panic, fear of impending death, d ysphoric affect, indigestion, anorexia, d yspnea, palpitations, generalized aches and pains, and a feeling of a mass in the epigastrium. koro A term, probably o f Malaysian origin, that refers to an episode of sudden and intense anxiety that the penis (or, in fem ales, the vulva and nipples) will recede into the bod y and possibly cause death. The syndrome is reported in sou th and east Asia, where it is kno wn by a variety of local terms, such as s/lllk yang, shook yong, and SIlO yang (Chinese); jilljillia bemar (Assam); or rok-joo (Thailand). It is occasionally found in the West. Koro at times occurs in localized epidemic form in east Asian areas. This diagnosis is included in the Chillese Classificatioll of Mell tal Disorders, Second Edition
(CCMO-2).
Outline for Cultura l Fo rmula t ion and Glossary of Culture-Bound Syndro mes latah H ypersensitivity to sudden fri ght often with echopraxia, echolalia, command obedience, and d issociative or trancelike behavior. The tenn latall is of Malaysian or Indones ian origin, but the syndrome has been fOlUld in many parts of the world. Other terms for this condition are alllllrakh, irkilll;i, ikota, olafl , myriachit, and menkeiti (Si berian groups); bah Iseh;, bah-tsi, and baall-ji (Thailand); ill/u (Ainu, Sakhalin, Japan); and lIIali-lIIali and silok (Philippines). In Malaysia it is m ore frequent in m iddle-aged women. locura A term lIsed by Latinos in the United States and Latin America to refer to a severe form of chronic psychosis. The condition is a ttribu ted to an inherited vulnerability, to the effect o f multiple li fe difficulties, o r to a combination of both factors. Symptoms exhibited by persons with locura include incoherence, agitation, auditory and visual hallucinations, inability to foUow rules of social interaction, unpredictability, and possible violence. mal de oja A concept widely found in Mediterranean cultu res and elsewhere in the world. Mal de oja is a Spanish phrase translated into English as "evil eye." Children are especially at risk. Symptoms include fitful s leep , crying without apparent cause, diarrhea, vomiting, and feve r in a child or in fan t. Sometimes adults (esp eciall y females) have the condition. nervios A common idiom of distress among Latinos in the United States and Latin America. A number of other eUmic groups h ave related, though o ft en somewhat d istinctive, ideas of "nerves" (such as IICllm among Greeks in North America). Nervios refers both to a general state of vulnerability to s tressful life experiences and to a synd rome brough t on by difficult life circums tances. The term lIeroios includes a wide range of symptoms of emotional d is tress, somatic disturbance, and inability to function. Common symptoms include headaches and "b rain aches," irritability, s tomach dis turbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensa tions, and lIlarf'OS (dizziness with occasiona l vertigolike exacerbations) . Nervios tend s to be an ongoing p roblem, although variable in the degree of d isability manifested. Nervios is a very broad syndrome that spans the range from cases free of a men tal d isorder to presentations resembling Adju stmen t, Anxiety, Depressive, Dissociative, Somatoform, or Psychotic Disorders. Differential diagnos is will depend on the constellation of sym p toms experienced, the kind of social events that are associated with the onset and progress of nervios, and the level of disability experienced . pibloktoq An abrupt dissociative episode accompanied by extreme exci tement o f up to 30 minutes' duration and frequently foll owed by convulsive seizures and coma lasting up to 12 hours. This is observed p rimarily in arctic and subarctic Eskimo comffi lUlities, although regional var iations in name exist. The individual may be withd rawn or mildly irritable for a period of hours or days before the attack and will typically re port complete amnesia fo r the attack. During the attack, the individua l may tear off his or her clothing, break furniture, s hout obscenities, eat feces, flee from protective s helters, or perfonn other irrational o r dangerous acts.
Appendix I qigong psychotic reaction A term describing an acute, time-limited episode char acterized by dissociative, paranoid , or o ther psychotic or non psychotic symptoms that may occur after pa rticipation in the Chinese fol k healthenhancing practice of qigong ("exercise of vital energy"). Especially vulnerable are individuals who become overly involved in the practice. This diagnosis is included in the Chinese Clnssification of Mentnl Disorders, Second Edition (CCMD-2). roo h .... ork A set of cultural interpretations that ascribe illness to hexing, witchcraft, sorcery, or the evil influence of another person. Sympto ms may include generalized anxiety and gastrointestinal complaints (e.g., nausea, vomiting, diarrhea), weakness, dizziness, the fear of being poisoned, and sometimes fear o f being killed ("voodoo death "). " Roots," "spells," or "hexes" can be "put" or placed on other persons, causing a variety of emotional and psychological problems. The "hexed" person may even fear death until the " root" has been " taken off" (eliminated), usually through the work of a "root doctor" (a hea ler in this tradition), who can also be called on to be witch an enemy. " Rootwork" is found in the southern United States among both African American and European American populations and in Caribbean societies. It is also known as IIInl pllesto or brujerin in Latino societies. sangue d onnido ("sleeping blood ") This syndrome is found among Portuguese Cape Verde Islanders (and immigrants from there to the United States) and includes pain, numbness, tremor, paralYSiS, convulsions, stroke, blindness, heart attack, infection, and miscarriage. shenjing shuairu o ("neurasthenia") In China, a condition characterized by physical and mental fatigue, dizziness, headaches, other pains, concentration difficulties, sleep disturbance, and memory loss. O ther symptoms include gastrointestinal problems, sexual dysfunction, irritabili ty, eXCitability, and various signs suggesting disturbance of the autonomic nervous system. In many cases, the symptoms would meet the criteria for a DSMIV Mood or Anxiety Disorder. This diagnosis is induded in the Chinese Classificatioll of Melltal Disorders, Second Edition (CCMD2). shen-k'uei (Taiwan); shenkui (China) A Chinese folk label describing marked anx ietyor panic symptoms with accompanying somatic complaints for which no physical cause can be demonstrated. Symptoms include dizziness, backache, fatigability, general weakness, insomnia, frequent dreams, and complaints of sexual d ysfunction (such as premature ejaculation and impotence). Symptoms are attributed to excessive semen loss from frequent intercourse, masturbation, nocturnal emission, or passing of "white turbid urine" believed to contain semen. Excessive semen loss is feared because of the belief that it represents the loss of one's vita l essence and can thereby be life t1ueatening. shi n-byung A Korean folk label for a syndrome in which initial phases are charac terized by anxiety and somatic complaints (general weakness, dizziness, fea r, anorexia, insomnia, gastrointestinal p roblems), with subsequent dissociation and possession by ancestral spirits.
Outli ne for Cult ura l Fo rmulation and Glossary of Cultu re-Bound Syndromes spell A trance state in which individuals "communica te" with deceased relatives or with spirits. At times this state is associa ted with brief periods of personality change. This culture-specific syndrome is seen among African Americans and European Americans from the southern United States. Spells are not considered to be medical events in the folk tradition but may be misconstrued as psychotic episodes in clinical settings. susto ("fright," or "soul loss") A folk illness prevalent among some Latinos in the United States and among people in Mexico, Central America, and South America. Susto is also referred to as espallto, paSIIlO, tripa ida, perdida del alma, or c1libih. Susto is an illness attributed to a fr ightening event that ca uses the soul to leave the body and results in unhappiness and sickness. Individuals with suslo also experience significant strains in key social roles. Symptoms may appear any time from days to years after the fri ght is experienced . It is believed that in extreme cases, susto may result in death. Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, feeling of sadness, lack of motiva tion to do anything, and feelings of low self-worth or dirtiness. Somatic symptoms accompanying susto include muscle aches and pains, headache, stomachache, and diarrhea. Ritual healings are focu sed on calling the soul back to the body and cleansing the person to restore bodily and spiritual balance. Different experiences of susto may be related to Major Depressive Disorder, Posttraumatic Stress Disorder, and Somaloform Disorders. Similar etiological beliefs and symptom configurations are found in may parts of the world . taijin kyofusho A culturally distinctive phobia in Japan, in some ways resembling Social Phobia in DSM-IV. This syndrome refers to an individual's intense fear that hi s or her body, its parts or its fun ctions, displease, embarrass, or are offensive to other people in appearance, odor, facia l expressions, or movements. This syndrome is included in the official Japanese d iagnostic system for mental disorders. zar A genera l term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other 'orth African and Middle Eastern societies to the experience of spirits possessing an ind ividua l. Persons possessed by a spirit may experience dissociati ve episodes that may include shouting, laughing, hitting the head against a wall, singing. or weeping. lndividuals may show apathy and withdrawal, refusing to ea t or carry out daily tasks, or may develop a long-tenn relationship with the possessing spirit. Such behavior is not considered pathological locally.
Appendix J
DSM-IV Contributors
B ecause DSM-IV is meant to be used by a diverse group of men tal health professionals in a variety 01 settings, the Task Force on DSM-IV and the Work Groups solicited and encouraged the participation of a wide range of professionals to serve as
advisers to the Task Force and individ ual ''''ork Groups. Ad visers incl uded individ uals from other health associations; clinical practitioners; researchers; forensic s pecialists; experts on gender, age, and c ultural issues; and international experts.
905
Appendix J Richard Heimberg, Ph.D. John E. H elzer, M .D. Judith Herman, M.D. Rudolf Hoehn-Saric, M.D. Steven Ken Hoge, M.D. Eric H ollander, M.D. Mardi H orowitz, M.D. Tom Insel, M.D. Michael Jenike, M.D. '''layne Kato n, M.D. Heinz Katscimig, M.D. Terrance Keane, Ph.D. Dean Kilpatrick, Ph .D. Laurence Kirmayer, M.D. Donald F. Klein , M.D. Stuart Kleinman, M.D. Gera ld L Kle rman, M.D. (deceased ) Lawrence Kolb, M.D. Michael J. Kozak, Ph.D. Cynthia Las t, Ph.D. Bernard Lerer, M.D. Andrew Levin, M.D. R. Bruce Lydia rd, M.D., Ph.D. Salva tore Mannuzza, Ph.D. John S. March, M.D. Andrew Mathews, Ph.D. Matig Ma vissakalian, M .D. Alexander McFarlane, M.B., B.S. (H a ns), M.D. Richard Mc ally, M.D. Cha rles A. Meyer, Jr., M.D. Ka rla Moras, Ph.D. Dennis Munjack, M.D. Lars Goran Ost, Ph.D. Howard Parad, O.5.W. Kok Lee Peng, M.D. Roger Pitma n, M.D. Robert Pynoos, M.D. Ronald M. Rapee, Ph.D. Beverley Raphael, M.D. Steven Ras mussen, M.D. James Reich, M.D., M.P.H. Patricia A. Resick, Ph.D. Jeffrey C. Richards, Ph. D. Ka rl Rickels, M.D. John H. Ris kind, Ph.D. Sir Martin Roth, M.D. Ba rbara Rothba um, Ph.D. Peler Roy-Byrne, M.D. Philip Saigh, Ph.D. Paul Salkovskis, Ph.D. W illiam C. Sanderson, Ph. D. Franklin Schneier, M.D. Javaid Sheikh, M.D. Za hava Soloman, M.D. Susan Solom on, Ph.D. La rry H . Strasburger, M .D., Ph.D. Suzanne Sutherland, M.D. Richard Swinson, M .D. Le nore Te rr, M.D. Peter Trower, Ph.D. Samuel M. Turner, Ph.D. Thomas Uhde, M.D. David Watson, Ph.D. Hans Ulrich Wittchen, Ph.D. Patti Zetlin, M.5.W. Richard Zinbarg, Ph.D. Joseph Zohar, M.D. Delirium, Deme ntia, and Amnestic and Othe r Cogn itive Disorders Ad visers Frank Be nson, M.D. John Sreitner, M.D. Sieve Buckingham, M .S.s.W . Nelson Butters, Ph.D. Steven Cohen-Cole, M.D. Jeffrey Lee Cummings, M.D. H oracia Fa brega, Jr., M.D. Barry Fogel, M.D. Robert P. Granacher, M.D., Ph.D. Robert C. Green, M.D. Robert Hea ton, M .D. Steven Ken H oge, M.D. K. Ra nga Rama Krishnan, M.D. Ke h-Ming Lin, M.D. Zbigniew Lipowski, M.D. Alw yn Lishman, M .D. Richard Mayeux, M.D. Marsel Mesulam, M.D. Vernon. Neppe, M .D. Barry Reisberg, M .D. Sir Martin Roth, M.D. David Rubinmv, M.D.
1
DSM-IV Contributors Randy Schiffer, M.D. Michael Taylor, M.D. Linda Teri, Ph.D. Allan Yozawitz, M.D. Stuart C. Yudofsky, M.D. Michael Zaudig, M.D.
Disorders Usu ally First Diagnosed Durin g Infancy, Chil dhood, or Adolesce nce Advisers Marc Amaya, M.D. U sa Amaya-Jackson, M.D. Adrian Angold, M.B., B.s., M.R.C.Psydl. William Arroyo, M.D. Robert F. Asarnow, Ph.D. George Bailey, M.D. Joseph Biederman, M.D. Ray Blanchard, Ph.D. Lewis M. Bloomingdale, M.D. John Bradford, M.D. Joel Bregman, M.D. Glorissa Canino, Ph.D. Ian Alberto Canino, M.D. Iris Chagwedera, Ph.D. Dante Cicchetti, Ph.D. Susan Coates, Ph.D. Patricia Cohen, Ph.D. C. Keith Conners, Ph.D. Jane Costello, M.D. Charles Davenport, M.D. Robert Delong, M.D. Martha Denckla, M.D. Park Elliott Dietz, M.D., Ph.D. Craig Donnelly, M.D. Felton Earls, M.D. L. Erlenmeyer-Kimling, Ph.D. Jack Fletcher, Ph.D. Steven Forness, Ed .D. Richard Green, M.D., J. D. Laurence Greenhill, M.D. Stanley Greenspan, M.D. Richard L Gross, M.D. Robert Harmon, M.D. Lily Hechtman, M.D. Margaret Hertzig, M.D. James J. Hudziak, M.D. Peter Jensen, M.D.
Gloria Johnson-Powell, M.D. Robert King, M.D. Mindy Krotick, M.A. Cynthia Last, Ph.D. James Leckman, M.D. James Lee, M.D. Stephen Levine, M.D . John Lachman, M.D. Catherine Lord, Ph .D. John S. March, M.D. James McKinney, Ph.D. Jon Meyer, M.D. Heino F. L. Meyer-Bahlburg, Dr., rer., nat. Juan Enrique Mezzich, M.D., Ph.D. Klaus Minde, M.D. David Mrazek, M.D. Joy Osofsky, Ph.D. Ira Pauly, M.D. Gary Peterson, M.D. Sally Provence, M.D. Joaquim Puig-Antich, M.D. (deceased) Kathleen May Quinn, M.D. Steven Rasmussen, M.D. Robert J. Reichler, M.D. Mark A. Riddle, M.D. Edward Ritvo, M.D. Richard Rosner, M.D. Byron Rourke, Ph.D. Diane H . Schetky, M.D. Eric Schopler, Ph.D. Rourke Schopler, Ph .D. Arthur Shapiro, M.D. Theodore Shapiro, M.D. Bennet Shaywitz, M.D. Larry Silver, M.D. Robert Stoller, M.D. (deceased ) Alan Stone, M.D. Peter Szatmari, M.D. Ludwig Szymanski, M.D. Paula TallaL Ph.D. Kenneth Towbin, M.D. Luke Tsai, M.D. Kenneth Jay Weiss, M.D. Myrna M. Weissman, Ph.D. Elizabeth Weller, M.D. Karen Wells, Ph.D.
908
Agnes l,oVhittaker, M.D. Janet 8. W. Williams, D.S.W. Ronald Winchel, M.D. Allan Yozaw itz, M.D. Kenneth J. Zucker, Ph.D. Barry Zuckerman, M.D. Bernard Zuger, M.D.
Eating Disorders Adv isers W. Stewart Agras, M.D. Arnold Anderson, M.D. William Sennan, Ph.D. Peler Beumont, M.D. Barlon J. Blinder, M.D. Susan Jane Blumenthal, M.D. LCDR James M. Blunt Harry A. Brandt, M.D. Timothy D. Brewerton, M.D. Kelly BrowneU, Ph.D. Gabrielle A. Carlson. M.D. Eva Carr, M.A. Regina Cas per, M.D. Leslie Citrome, M.D. Peter J. Cooper, MD. Arthur H. Crisp, M.D. Maria DaCosta, M.D. Bonnie Dansky, Ph.D. Michael Dev lin, M.D. Adam Drewnowski, Ph.D. Elke Eckert, M.D. Rohert Edelman, M.D. Christopher Fairburn, M.D. Madeline Fernstrom , Ph.D. Manfred Fichter, M.D. Martine Flamenl, M.D. Henri Flikier, A.C.S.W. Victor Fornari, M.D. Chris Freeman, M.D. David M. Ga m er, Ph.D. Philip W. Gold, M.D. Harry E. Gwirtsman, M.D. Deborah Hasin, Ph.D. C. Peter Herman, Ph.D. David Herzog, M.D. Jules Hirsch, MD. Hans W. Hoek, M.D., Ph.D. Steven Ken Hoge, M.D.
Appendix J
DSM -IV Contributors Albert J. Stunka rd, M.D. Allan Sugarman, M.D. George Szmukler, M.D. Ste n Theander, 1.0. Suellen Thomsen, B.A. David Tobin, PhD. Walter Vandereycken, fvl.D. David Veale, M.R.C.Ps}'ch . Kelly Bemis Vi tousek, PhD. Thomas Wadden, Ph.D. David Waller, M.D. Winny Weed.a-Manna k, Ph.D. H e rber t Weiner, M.D. Mitchel Weiss, M.D., Ph .D. David Wheadon, M.D. Rena Wing, M .D. Ste ve Wonderlich, Ph.D. Susan Wooley, Ph.D. Wayne Wooley, Ph.D. Judith Wurtman, Ph.D. Joel Yager, M.D. Susan Yanovski, M.D. Pres ion Zucker, M.D. Mood Disorders Advi sers H agop Akis kal, M.D. Jay Am s terdam, M.D. Jules Angst, M.D. Paul S. Ap pelbaum, M.D. Marie Asberg, M.D. David Avery, M.D. Aaron T. Beck, M .D. James C. Beck, M .D. Dan Blazer, M.D. Charles Bowd en, MD. Ian Brocking ton, M.D. Susan B. Campbell, Ph.D. De nnis P. Cantwell, M. D. Bemard 1. Carroll, M. D. Ph .D. G iovanni Cassano, 1\'1. 0. Pa ul Chodoff, M.D. '\' illiam Coryell, M.D. John L. Cox, D.M. Jonathan Da vidson, M.D. John Davis, M.D. Chris tine Dean, M.D. Robe rt Delong, M.D. J. Raymond DePaulo, M.D. Jean Endicott, Ph.D. Cecile Ernst, M.D. Max Fink, M.D. Les lie M. Forman, M.D. Linda George, Ph.D. Robert Gerner, M. D. Elliot Gershon, M.D. William Gold stein, M.D. Byron Good, Ph .D. Frederick K. Goodwin, M.D. Thomas G ordon Gutheil, M.D. \'Vilma M. H arrison, M.D. Jonathon M. Himmelhoch, M.D. Robert M. A. H irsdlfeld, M.D. Steven Ken Hoge, M.D. Charles Holzer IU, M.D. Robert H owland, M.D. Emily H oyer. B.A. James Jefferson, M.D. Ira Katz, MD. Gabor Keitner, MD. Robert Kendell, M .D. Kenneth S. Kendler, M.D. Daniel Klein, Ph.D. Gerald L. Klerman, M. D. (deceased) James Kocsis, M.D. Ha rold Koenig, M.D. Ernes t Kovacs, M.D. Helena Kraemer, Ph .D. K. Ranga Rama Kris hnan, M. D. Andrew Krystal, M.D. David J. Kupfer, M.D. Jacqueline LaUve, M.D. Peter Lewinshon, Ph.D. Wolfgang Maier, M.D. John Mann, M.D. Spero Manson, Ph.D. James P. McCullough, Ph .D. Patrick McGra th, M.D. Julien Mendelewicz, M.D. Kathleen Merikangas, Ph.D. Robert Michels, M.D. Ivan Miller, Ph.D. Phyllis Nash, DSW. Mich ael O 'H ara, PhD. David O sse r, M.D.
Appendix J Gordon Parker, M.D. Barbara Parry, M.D. Eugene Payke\, M.D. Kok Lee Peng, M.D. Fredrick Petty, M.D., Ph.D. Robert M. Post, M.D. Daniel Purdy, AB. Frederic Quitkin, M.D. Judith G. Rabkin, Ph.D. Ted Reich, M.D. Richard Ries, M.D. Donald Robinson, M.D. Holly Rogers, M.D. Jerrold F. Rosenbaum, M.D. Norman Rosenthal, M.D. Anthony Rothschild, M.D. Alec Roy, M.D. Cord elia Russell, B.A Alan Schatzberg, M.D. Jan Scott, Ph.D. Tracie Shea, Ph.D. Anne Simmons, Ph.D. Stuart Sotsky, M.D. David Steffens, M.D. Jonathan Stewart, M.D. Larry H . Strasburger, M.D., Ph.D. Trisha Suppes, M.D., Ph.D. Michael Tha se, M.D. Richard Weiner, M.D. Jan Weissenburger, M.A. Myrna M. Weissman, Ph.D. Kenneth Wells, M.D. Peter C. Whybrow, M.D. George Winokur, M.D. Anna '<\' irzJustice, Ph.D. Hans Ulrich Wittchen, Ph .D. M u ltiaxial Issues Advisers Jonathan F. Borus, M.D. Kathleen Buckwalter, Ph.D. Fredric Busch, M.D. Eric Douglas Caine, M.D. Thoma s Carli, M.D. Arnold Cooper, M.D. Paul C rits-Christoph, M.D. Su san Fine, M.A Paul 1. Fink, M.D. Jack Froom, M.D. Ama Fujinawa, M.D. Daniel W. Gillette, M.D. Robert Glick, M.D. Byron Good, Ph.D. Richard E. Gordon, M.D., Ph.D. Barry Gurland, M.D. Herta A. Guttman, M.D. Richard Hall, M.D. Mardi Horowitz, M.D. Charles Hughes, Ph.D. T. Byram Karasu, M.D. James Karls, O.S.W. Florence Kaslow, Ph.D. Otto Kernberg, M.D. Gerald L. Klerman, M.D. (deceased) Thomas Kuhlman, Ph.D. PoweD Lawton , Ph.D. Joshua D. Lipsitz, Ph.D. C hristine Lloyd, M.D. Lester Luborsky, M.D. Roger Mackinnon, M.D. Carolyn Mazure, Ph.D. Theodore Millon, Ph.D. Gleo Pearson, M.D. J. Christopher Perry, M.D. George H . Pollock, M.D. Joseph M. Rey, Ph.D. Lawrence Rockland, M.D. Geoffrey Shrader, M.D. Rona ld C. Simons, M.D., M.A. Alan Stoudemire, M.D. James J. Strain, M.D. John S. Stra-'1ss, M.D. Christopher Tennant, M.D. Mary Durand Tho mas, R.N., Ph .D. Virginia Tilden, R. ' ., D.N.Se. George Vaillant, M.D. Holly Skodol Wilson, R.N., Ph.D. Ronald M. Win trob, M.D. Lyman C. Wynne, M.D., Ph.D. Personality Disorders Advisers Gerald Ad ler, M.D. Salman Akhtar, M.D. Hagop Akiskal, M.D. Norimassa Akuta, M.D .
I
DSM -IV Contributors Renato Daniel Alarcon, M.D., M.P.H. Arthur Alterman, Ph.D. Antonio Andreoli, M.D. Paul S. Appelbaum, M.D. Beng-Ake Armelius, Ph.D. Lorna Smith Benjamin, Ph.D. Mark Berelow itz, M.D. Jack Brandes, M.D. Remi Cadoret, M.D. Paul Chadof, M .D. Lee Anna C lark, Ph. D. John Clarkin, Ph.D. e. Robert Cloninger; M.D. Jerome Cohen, D.5.W. Kar"}'l Cole, MD. Arnold Cooper, M.D. Paul Costa, Ph.D. Alv A. Dahl, M.D. Carl Eisdorfer, M.D., Ph.D., M.5.W Edward F. Foulks, M .D., Ph.D. John Frosch, M.D. William Goldstein, M.D. Seymour L. Halleck, M.D. Robert Hare, Ph.D. Judith Hennan, M.D. Steven Ken Hoge, M.D. Mardi Horowitz, M.D. Stephen W. Hurt, Ph.D. Steven Hyler, M.D. Karen John, M.D. Patricia Judd, MSW. Charles Kaelber, M.D. Oren Kalus, M .D. Kenneth S. Kendler, M.D. Otto Kernberg, M.D. Donald Kiesler, PhD. Daniel Klein, Ph .D. Donald F. Klein, M.D. Arthur Kleinman, M.D., Ph.D. Harold Koenigsberg, M.D. Jerome Kroll, M.D. Marsha Linehan, Ph.D. Paul Links, M.D. John Lion, MD. W. John Livesley, M.D. Armand Loranger, Ph.D. Spencer Lyerly, Ph.D. Michael Lyons, Ph.D. K. Roy MacKenzie, MD. Roger Mackinnon, M.D. N ikolas Manos, M.D. James Mas terson, M.D. Robert McC rae, Ph.D. Thomas McGlashan, M.D. Robert David Miller, M.D., Ph.D. Leslie Morey, Ph.D. Ole Mors, M.D. Kazuhisa Nakao, M .D. H . George N umberg, MD. John Oldham, M.D. Yutaka O no, M .D. Stephen L. Ox ley, Ph.D. Joel Paris, M.D. Gordon Parker, MD. Glen Pearson, M.D. Kok Lee Peng, M.D. Christopher Perry, MD. Ethel Person, M.D. Katharine Anne Phillips, M.D. Paul Pilkonis, Ph.D. Harrison Pope, M.D. C harles PuU, M.D. James Reich, M.D., M.P.H. William H. Reid, M.D. Lee Robins, Ph.D. Elsa Ronnings tam, PhD. Loren Henry Roth, M.D. Robert Ruegg. M.D. Pedro Ruiz, M.D. A. Jolm Rush, M.D. Man' in Sch wartz, M.D. Richard Selman, M.D. Kenneth Silk, M.D. Bennett Simon, M .D. Richard e. Simons, M.D. Erik Simonsen, MD. Andrew Edward Skodol II, M .D. Paul Harris Soloff, M.D. Stephen Sternbach, MD. Alan Stone, M.D. Michael Stone, MD. Lawrence Tancredi, MD. Alex Tamopolsky, M.D. Auke Tellegen, Ph.D.
912
Pekka Tienari, M .D. Svenn To rgensen, M.D. Joseph Triehwasser, MD. Rohert Tringone, Ph.D. Timothy Trull, Ph .D. Peler Tyre r, M.D. Lind sey Tweed, M.D. T. Bedirhan Ustun, M .D. Per Vaglum, rvLD. Sonya Vaglum, M.D. George Vailla nt, M D . Le nore B. ' <\'a lker, Ed. D.
Appendix J
David Rubinow, 1'1.0. Paula Schnurr, Ph.D. John Steege, M.D. ;"'Ieir Steiner, M. D., Ph.D. Donna Stewa rt, M.D. Anna Stout, MD. Lenore 6 . ' '''alker, Ed.D. David Youngs, M.D.
Psychiatric Systems In terface Diso rders (Adjustmen t, Dissociative, Factitious, Impulse-Control, and Soma toforrn Disorders and Psycholog ical Factors Affecting Medical Co ndition) Advise rs Paul S. Appelbaum, M.D. Allyson As h ley, D.5.W. A rthur J. Ba rsky, M.D. David H . Ba rlow, Ph.D. Johnathon O. Beahrs, M.D. Da vid Bear, M.D. Gale Beards ley, M.D. Sidney Benjamin, M.D., ~l.Ph iL Kenneth Bowers, Ph .D. John Bradford, M.D. Bennett Braun , M.D. Etzel Cardena. Ph.D. James Chu, M. D. Catherine Classen, Ph .D. Philip Coons, M.D. Douglas Detrick, Ph.D. Robert H . Dworkin, Ph.D. David Folks, M.D. Fred Frankel. M.D. Edward Frischholz, Ph.D. George Fulup, M.D. Ro llin Gallagher, M.D. Jeffrey Geller, M.D. Daniel W. Gillette, M.D. Michael G. Golds tein, M.D. Veerainder Goli, M.B. Carlos A. Gonzalez, M.D. Junius Gonzales, M.D. Michael r. Good, M.D. Ezra E. H. Griffith, M.D. Sa muel B. Guze, M.D. Seymour L Halleck, M.D.
Premenstrual Dysphoric Disorder Advisers Elissa P. Benedek, M.D. Sa rah Berga, lvl. D. Susan Jane Blumenthal, M.D. Leah Joan Dickstein, M.D. Ellen W. Freeman, Ph.D. Sheryl Galla nt, Ph .D. Leslie Gise, M.D. Uricl Halbreich, M.D. Jean Ham ilton, M.D. Michelle Harrison, M.D. Roger F. Haskett, M.D. Steven Ke n H oge, M.D. Stephen W . Hurt, Ph.D. Renee Johns, B.A . W. Keyc, Jr., M.D. Martha Kirkpa trick, M.D. Martha McClintock, Ph.D. Margaret L. Moli ne, Ph.D. Carol C. ' adelson, M.D. Howard Osofsky, M.D. Mary Brown Parlee, Ph.D. Jeff Rausch, M.D. Robert Reid, M.D. R. Rhodes, M.D. Ana Rivera-Tovar, Ph.D. Gai l Robinson, M.D. Miriam Rosenthal, M.D. Peter Roy-Byrne, M.D.
DSMIV Contributo rs
913
Stephen M. Saravay, M.D. Jonathon F. Silver, M.D. Herbert Spiegel, M D . Marlene Steinberg, M.D. Robert Stewart, O.S.W. Marvin Swartz, MD. Troy L. Thompson il, M.D. Moshe Torem, M.D. Eldon Tunks, M.D. William L Webb, Jr., M.D. (deceased) Kenneth Jay Weiss, M.D. Mitchel Weiss, M.D., Ph.D. Lewis Jolly West, M. D. Ronald Winchel, M.D. Thomas Na than Wise, M.D. Dennis Wolf, M.D. Derson Young, M.D. Stuart C. Yudofsky, M.D. Sean Yu tzy, M.D. Schizophrenia and Other Psychotic Disorders Advisers Xavier Amador, PhD. Stephan Arndt, PhD. Peter Berner, M.D. Istvan Bitler, M.D. Donald W. Black, M.D. Randy Borum, M.D. Malcolm B. Bowers, Jr., M.D. H. Stefan Bracha, M.D. Ian Brockington, M.D. William Carpenter, M.D. Richard J. Castillo, Ph.D. David Copolov, 1 1. 0 . .... Lawrence A. Dunn, M.D. William Edell, Ph.D. Akira Fujinawa, M.D. Carlos A. Gonzalez, M.D. Jack Gorman, MD. Igor Gra nt, MD. Ezra E. H. Griffith, M.D. Gretchen Haas, Ph. D. Martin Harrow, Ph.D. Steven Ken Hoge, M.D. Janis H. Jenkins, Ph .D. Dilip V. Jeste, M.D. Marvin Kama, M.D.
Abraham L H alpern, M.D., Ph.D. Nelson Hendler, r"I.5., M.D. Ernest Hilgard , Ph.D. Steven Ken Hoge, M.D. Jimmie C. Holland, M.D. Eric Hollander, M.D. James J. Hudziak, M.D. Janis H. Jenkins, Ph.D. Roger Kathol, M.D. J. David Kinzie, M.D. Laurence Kirmayer, M.D. Arthur Kleinman, M.D., Ph.D. Richa rd Kluft, M.D. C heryl Koopman, Ph.D. Donald S. Kornfeld, M.D. K. Ranga Rama Krishnan, M.D. John Kurtz, M.D. Henry R. Lesieur, Ph.D. James Levenson, M.D. Roberto Lewis-Fernand ez, M. D. John Lion, M.D. Zbigniew J. Lipowski, M.D. Don R. Lipsitt, M.D. Richa rd Loewenstein, M.D. Jeffrey Mattes, M.D. M. Eileen MC! amara, M.D. Harold Merskey, D.M. Michael Moran, M.D. George B. Murray, M.D. John Nemiah, M.D. Jeffrey Newcom, M.D. Raymond Niaura, Ph.D. Perry M. Nicassio, Ph.D. Martin Orne, M.D., Ph.D. Kal pana Pakianathan, M.D. Robert o. Pasnau, ~I.D. Kok Lee Peng, M.D. Samuel W. Perry m, M.D. Gary Peterson, M.D. John Plewes, M.D. Stanley L. Portnow, M.D., Ph.D. Frank Putnam, M.D. Phillip Jacob Resnick, M.D. Richard J. Rosen thal, M.D. Colin A. Ross, M.D. JO Z. Sadler, M.D. IUl Shirley Sanders, Ph.D.
914
Rohert Kendell, M.D. Anthony F. Lehman, M.D., M.5.P.H. Roberto Lewi s-Fernandez, M.D. Robert liberman, M.D. Jeffrey Ueberman, M.D. Mario Maj, M.D. Joseph P. McEvoy, M.D. Max McGee, M.D. Patrick McCorry, M.RBS. Herbert Meltzer, M.D. Alan Metz, M.D. Jeffrey L Metzner, M.D. Mark Richard Munetz, M.D. Alis tair Munroe, M .D. Keith 'euchterlein, Ph .D. Yuji Okazaki, M.D. AUonso Ontiveros, M.D., M.Sc. Stein Opjords moen, Ph. D. Ananda K. Pandurangi, M.D. GOd frey Pearisan, M.D. Delbert Robinson, M.D. N ina Schooler, Ph.D. Larry Siever, M.D. Samuel Siris, M.D. John Sweeney, Ph.D. Sally Szymanski, D.o. Mauricio Tohen, M.D. Ming Tso Tsu ang, M.D., Ph.D. Michael Zaudig, M.D. Sexual Disorders Advisers John Bradford, M.D. Robert P. Cabaj, M.D. Dona L. Davis, Ph .D. Park Elliott Dietz, M.D., Ph.D. Leslie Gise, M.D. Abraham L. Halpern, M.D., Ph.D. Gilbert Herdt, Ph.D. Ste....en Ken Hoge, M .D. Helen Kaplan, M.D. Kok Lee Peng, M.D. Anna Stout, M.D. Sleep Disorders Advisers Edward Bixler, M.D. Jack Edinger, M.D. Charles W. Erwin, M.D.
Appendix J
Eugene C. Fletcher, M .D. Abraham L. Halpern, M.D., Ph.D. Peter Hauri, Ph.D. Anthony Kales, M.D. Milton Kramer, M.D. Rocco Manfredi, M.D. Gail Marsh, M.D. Jeffrey L. Metzner, M.D. Harvey Moldofsky, M.D. Timothy H . Mon k, Ph.D. Ralph PascuaJy, M.D., R.N. Howard Rofn .... arg.. M.D. Thomas Roth, Ph.D. A John Rush, M.D. Constantin R. SoJdatos, M.D. Edward Stepanski, Ph.D. Michael Thorpy, M.D. Substance Related Disorders Ad .... isers Henry Abraham, M.D. Chris ter Allgulander, M.D. Arthur Alterman, Ph.D. Roland Atkinson, M .D. Tom Babor. Ph.D. George Bailey, M.D. James Barbie, M.D. Jeffrey Bedrick, M.D. Fred K. Berger, M.D. Jack D. Blaine, M.D. Sheila Blume, M.D. Richard Bormie, J.D. Ka thleen Bucholz, Ph.D. John Cacciola, Ph.D. Glorissa Canino, Ph.D. William D. Clar k, M.D. Stephen Dinwiddie, M.D. Griffith Edwards, M.D. Marian Fischman, Ph.D. Richard Frances, M.D. William Frosch, M .D. Marc Galanter, M.D. Frank Gawin, M.D. Edith S. Unansky Gomberg, Ph.D. Enoch Gordis, M .D. David Gorelick, M.D. Bridget Grant, Ph.D. Marcus Grant, Ph.D.
DSM-IV Contributors Lester Grinspoon, MD. Alfred H arkley, M.D. James Hartford, M.D. Deborah Hasin, Ph .D. Steven Ken Hoge, M.D. Arthur M. Horton, Ph.D. John R. H ughes, M.D. Michael Invin, M.D. Jerome Jaffe, M.D. Denise Kandel, PhD. Edward Kaufman, M.D. Herbert Kleber, M.D. Thomas Kos ten, M.D. Mary Jeanne Kreek, M .D. James Langenbucher, Ph.D. Edward D. Levin, Ph.D. Benjamin Liptzin, M.D. James Maddox, M.D. Enrique Madrigal, M .D. Peier Martin, MD. Roy Mathew, M.D. Wayne McFadden, M .D. Thoma s McLellan, Ph .D. Jack H. Mendelsohn, M.D. Roger Meyer, M .D. Norman Miller, MD. Robert Millman, M .D. Maristela Monteiro, M.D. Robert M. Morse, M.D. David F. Naftolowi lz, M .D. Paul Nagy Charles O 'Brien, M.D. Glen Pearson, M .D. Stanton Peele, Ph.D. Helen Pettinatti, Ph.D. Roy Pickens, Ph.D. Andrzej Piotrowski, M.D. Rumi Price, Ph.D. Anthony Radcliffe, M.D. Charles Riordan, M.D. Jed Rose, PhD. Bruce ROWlSaville, M.D. John Saunders, MD. Sidney H. SchnolI- MD. Charles K Schuster, Ph.D. Boris Segal, M .D. Roy Stein, M .D. Lee L Towle, PhD . John Tsuang, M .D. Harold Urschel! ill, M.D. Derm ot Walsh, M.B. Robert Weinrieb, M D . Joseph Westermeyer, M.D., Ph.D., M.P.H. Kenneth Win teTS, Ph.D. Sheldon Zimberg, M.D.
915
916
Freda Cheung, Ph.D. Ellen Corin, Ph.D. Dona L. Dav is, Ph.D. Armando Favazza, M .D. Candace Flemin g, Ph.D. Edwa rd F. Foulks, MD., Ph.D. Atwood Gaines, Ph.D. Albert Gaw, M.D. James Gibbs, Ph .D. Carlos A. Gonzalez, M.D. Ezra E. H. Griffith, MD. Peler ]. Guamaccia, Ph.D. Gilbert Herd I, Ph.D. Kim Hopper, PhD . Da vid Hufford, PhD. Charles Hughes, Ph. D. Janis H. Jenkins, Ph.D. Marvin Kama, M.D. Marianne Kastrup, M. D., Ph.D. ]. David Kinzie, M.D. Lau.rence Kirmayer, M .D. Paul Koegel, Ph .D. Robert F. Kraus, M .D. Tina K. Leonard-Green, MS, R.O. Roberto Lewis-Fe rnandez, rvl.D. T-Y Lin, MD. Roland Littlewood , M.B., D.Phil. Francis Lu, M .D. Enrique Madrigal, M.D. Theresa O 'Neil, Ph.D. Raymond Prince, M.D. Juan Ramos, Ph.D. Cheryl Ritenbaugh, Ph .D., M.P. H. Lloyd Rogier, Ph.D. William H. Sack, MD. Ihsan Salloum, M. D., M. P.H. Norman Sartorius, M. D., Ph.D. Catherine L Shisslak, PhD. Ronald C. Simons, M.D., M.A. Jeanne M. Spurlock, M.D. N icolette Teufel, Ph .D. James W. TIlOmp son, M.D., M.P.H. Wen-Shing Tseng, M.D. Mitchel "'leiss, M.D., Ph.D. Joseph Westermeyer, M.D., Ph.D.,
Append ix J
Ronald M. '>\' intTob, M.D. Joseph Yamamoto, M.D. Advisers on Family/Relational Issu es James Alexander, Ph.D. Arthur M . Bodin, Ph.D. Robert Butler, M.D. Pa tricia Chamberlain, Ph.D. Dante Cichetti, Ph.D. John Clarkin, Ph.D. Daniel Corwin, M .D. Mark R. Ginsberg, Ph .D. Michael J. Goldstein, Ph.D. Herta A. Gu ttman, M .D. r...lichael D. Kahn, Ph. D. Sandra Kaplan, M .D. Florence Kaslow, PhD. John F. Knutson, PhD. Jud y Magil, M.s.W. David Milkowitz, Ph.D. K Daniel O' Leary, Ph .D. David Olson, Ph.D. David Pelcovitz, Ph.D. Angus M. Strachan, Ph.D. Terry S. Trepper, Ph .D. Lyman C. W)'lme, M.D., Ph.D. Ramsy Yassa, M. D. Ad vise rs on Forensic Issues Paul S. Appelbaum, M.D. James C. Beck, M.D. Lewis M. l3loomingdale, M.D. Richard Bonnie, J.D. Jeffrey Lee C u mmings, MD. Jeffrey Geller, M.D. Robert P. Granacher, M.D., Ph .D. TIlOmas Gordon Gutheil, M .D. Abraham L. Halpern, M .D., Ph.D. Steven Ken Hoge, M.D. Stuart Kleinman, M.D. Jeffrey L Metzner, M.D. Charles A. Meyer, Jr., M.D. Robert David Miller, MD., Ph.D. Mark.Richard Munetz, M.D. Stanley L Portnow, M.D., Ph.D. Phillip Jacob Resnick, M.D. Richard Rosner, MD.
917 \
Alan Daniels Frank deGruy, MD. Susan Dime-Meenan Stacy Donovan, B.A . Richard Dudley, M .D. Suzanne Dworak-Peck Bruce Emery, AC.S.W . Spencer Falcon, M .D. Louis Fine, M .D. Susan Fine, M.A Rita Finnegan, R.R.A Gerald H. Flamm, M.D. Laurie Flynn, B.A. Raymond D. Fow ler, Ph.D. Richard Fran ces, M.D. Jack Froom, M .D. Robert W. Gibson, M.D. Junius Gonzales, M.D. Raphael S. Good, M .D. Robert C. Green, MD. Larry P. Griffin, MD. Claire G riffin-Francell, R. N. Alfred Harkley, M.D. N onnan B. Hartstein, M.D. Ann Hohmann, Ph.D. Theodore Hutch ison, M.D. Dale Johnson, Ph .D. John E. Joyner, M.D. Ha rold Kaminetzky, M.D. lra Katz, M.D. Jerald Kay, M.D. Kelly Kelleher, M.D. Helena Kraemer, Ph .D. John J. LaFerla, M.D. Marion Langer, Ph .D. Martha Lasseter, R.R.A . Philip Lavori, PhD. Lawrence N . Lazarus, M.D. Harriet Lefley, Ph .D. James Levenson, M.D. Frank Ling, M .D. Mack Lipkin, M .D. Don-David Lusterman, Ph .D. Richard M. Magraw, M.D. Kathryn Magruder, Ph .D., M. P.H. Dale Matthews, MD. Chuck Mi les, M.D.
Daniel W. Shuman Larry H. Strasburger, M.D., Ph .D. Kenneth Ja y Weiss, M.D. H owa rd Zonana, M.D. Advisers on Medication-J.nduced Movement Disorders Gerard Addonizio, M.D. Lenard AdJer, M.D. Burt Angrist, M.D. Ross 1. Baldessarini, M .D. Stanley N. Carof!, M.D. Daniel Casey, M.D. Jeffrey Lee Cununings, M.D. George Gardos, M .D. Allen Gelenberg, M.D. james Jefferson, M. D. Dilip V. Jeste, MD. John M. Kane, M.D. Paul E. Keck, M .D. James Levenson, M.D. Stephan C. Mann, M.D. Ananda K. Pandurangi, M.D. Patricia Rosebush, M.D. Virginia Susman, M .D. Peter Weiden, MD. Ramsy Yassa, M .D. Advisers to the Task Force on DSM-IV Boris M. As trachan, M .D. Robert Avant, MD. Jeanette Bair, B.s., M.B.A W. Robert Beavers, M.D. Jeffrey Bed rick, M.D. Carl Bell, MD. Ellen Berman, M .D. Eugene Broadhead, M.D., Ph.D. Lau ra Brown, Ph.D. Robert P. Cabaj, MD. Robert Cahan, MD. Robert Chiarello, M.D. 'yVilliam D. Clark, M.D. Steven Cohen-Cole, M.D. Lee Combri..nck-Graham, M.D. Vicky Conn , R. N . Harris Cooper, Ph.D. Michael Crouch, M.D.
Appendix J
Sheld on I. Miller, M.D. PaulO. Mozley, M.D. Kathi Pajer, M.D. Joseph Palombi, M.D. Robert C. Park, M.D. Elaine Purpel, M.5.W. Peter Rabins, M.D. Anthony Radcliffe, M.D. Richard Rahe, M.D. Peter Rappo, M.D. Marilyn Rosenson, M.5.W. Marshall Rosman, Ph .D. Don ald J. Scheel, M.D. Sidney H . Schnall, M.D. Diana Seebold, RR.A. Charles A. Shamoian, M.D., Ph.D. Steven Sharfstein, M.D. J. Gregory Shea Alfred Skinner, M.D. William W. Snavely Janet T. Spence Leon Speroff, M.D. Emanuel Steindler Melvin Stem, M.D. James E. Strain, M.D. Rev. Pa ul C. Tomlinson Michael B. Unhjem Jerome Vaccaro. M.D. Jeanne Van Riper, A.RT. Alan l Wabrek, M.D. Lenore B. Walker, Ed.D. Steven Wartman, M.D. Robert Weinrieb, M.D. Robert Weinstock, Ph .D. Bryant Welch, Ph.D. Eleanor White, Ph.D. Robert L Williams, M.D. Mark Wolraich, M.D. Dav id Youn gs, M.D.
International Advisers
The Task Force on DSM-rv sought the expertise of a wide range of international exp erts. The contributions of interna tional experts helped to enswe cultural sensitivity, applicability for international mental health professionals, and greater compatibility with ICD-10.International experts advised both the Task Force and individ ual Work Groups. Christer Allgulander, M.D. (Sweden) Paulo Alterwain, M.D. (Uruguay) Antonio Andreoli, M.D. (Switzerland) Jules Angst, M.D. (Switzerl and) Beng-Ake Armelius, Ph.D. (Switzerland) Marie Asberg, M.D. (Sweden) Tolani As uni, M.D. (Nigeria) Sid ney Benjamin, M.D., M.Phil (England) Mark Berelowilz, M.D. (England) Peter Berner, M.D. (Austria) Aksel Bertelsen, M.D. (Denmark) Peter Beumont, M.D. (Australia) ish'an Bitter, M.D. (Hungary) Ray Blanchard, Ph.D. (Canada) Daniel Bobon (Belgium) Jacek Bo mba, M.D. (Poland) Kenneth Bowers, Ph.D. (Canada) John Bradford, M.D. (Canada) Susan Bradley, M.D. (Canada) Jack Brandes, M.D. (Canada) Ian Brockington, M.D. (England) Graham Burrows, M.D. (Australia) Pa tricia Casey, M.D. (Ireland) Giovanni Cassano, M. D. (Italy) 000 Young Cha, M.D. (Korea) David M. Clark, Ph.D. (England) John E. Cooper, M.D. (England) Peter J. Cooper, M.D. (England) Daviq Copolov, M.D. (Austra li a) Jorge Costa e Silva, M.D. (Brazil) Arthw H. Cris p, M.D. (England) Stanislaw Dabrowski, MD. (Poland)
...,
DSM-IV Contributors Adrian Dafunchio, M.D. (Argentina) Alv A. Dahl, M.D. (Norway) Chris tine Dean, M.D. (Eng land) Horst Dilling, M.D. (Germany) Keith Stephen Dobson, Ph.D. (Canada) Griffith Edwards, M.D. (England ) Chris topher Fairburn, M.D. (England) Fran cois Ferrero, M.D. (Switzerland) Manfred Fichter, M.D. (Germany) Martine Flament, M.D. (France) Chris Freeman, M .D. (Scotland) Harold Freyberger, M.D. (Germany) Akira Fujinawa, M.D. (Japan) Paul Garfinkel, M.D. (Canada) Michael Gelder, M.D. (England) Semyon Gluzman, M.D. (former USSR) Judith H. Gold, M.D. (Canada) Marcus Grant, Ph.D. (Swi tzerland) Herta A. Guttman, r"t.D. (Canada) Heinz Hafner, M.D. (Germany) Robert Hare, Ph.D. (Canada) lily Hechtman, M.D. (Canada) Michiel W. Hengeveld, M.D., Ph.D. (Netherlands) C. Peter Herman, Ph.D. (Canada) Hans Hippius, M.D. (Germany) Willem M. Hirs, M.D. (Netherland s) Teo Seng Hock, M.D. (Singapore) Hans W. Hoek, M.D., Ph.D. (Netherlands) Yoshiko Ikeda, M .D. Oapan ) Assen Jablensk. y, M.D. (Bulgaria) " Aleksander Janca, M.D. (Switzerland) Philippe Jeammet, M.D. (France) Karen John, M.D. (England) Miguel Jorge, M.D., Ph.D. (Brazil) Ross S. Kalucy, M .D. (Australia) Marianne Kastrup. M.D., Ph.D. (Denmark) Heinz Katschnig, M.D. (Austria) Jus tin Kenardy, Ph.D. (Au stralia) Robert Kendell, M.D. (Scotland) Sid Kennedy. M.D. (Canada) Renard Knabbe, M.D. (Switzerland) Vladimir Kovalev, M.D. (former USSR) Evsey Krasik, M.D. (former USSR) Yves LeCrubier, M.D. (France) Pierre Leichner, M. D. (Canada) Jill Leolbonne, M.D. (England) Bernard Lerer, M.D. (Israel) Aubrey Levin, M.D. (South Africa) Paul Links, M.D. (Canada) Zbigniew lipowski, M.D. (Canada) Alwyn lis hman, M.D. (England) W. John lives!ey, M .D. (Canada) J. Lopez-Ibor, Jr., M .O. (Spain) Mario Maj, M.D. (Italy) Felice Lieh Mak (China) Nikolas Manos, M.D. (Greece) Isaac Marks, M.D. (England) Alexander C. McFarlane, M.B.BS. (Hons), M.D. (Australia) Patrick McGorry, M.RBS. (Australia) Julien Mendelewicz, M. D. (Belgium) Klaus Minde. M.D. (Canada) Harvey Moldofsky, M.D. (Canada) Maris tela Monteiro. MD. (Brazil) Stuart Montgomery, M.D. (England) Ole Mors, MD. (Denmark) Alistair Munroe, M.D. (Canada) Gulam Mustafa, MD. (Kenya) Yoshibumi T akane, M.D. Oapan) W.A. Nolen (Netherlands) Claes Norring, Dr.Med .Sc. (Sweden) Yuri N uller (former USSR) Ahmed Okasha, M.D. (Egypt) Yuji Okazaki, MD. Oapan) Yutaka Ono, M .D. Oapan) Alfonso Ontiveros. M.D., M.Sc. (Mexico) Stein Opjords moen, Ph. D. ( orway) John O rley, M.D. (Switzerland) Lars Goran Ost, Ph.D. (Sweden) Stefano Pallanti, M.D. (Italy) Joel Paris, ~I.D . (Canada) Gordon Parker, M.D. (Australia) Eugene Pay kel, M.D. (England) Kok Lee Peng, M.D. (Singapore) Uwe Henrick Peters, M.D. (Germany) Carlo Perris, MD. (Sweden) Pierre Pichot, M.D. (France) Andrzej Piotrowski, M.D. (Poland) Karl Picke, M.D. (Germany) Janet Polh'y, Ph.D. (Canada) Charles Pull, M.D. (Luxembourg)
,
Appendix J
Kari Pylkkanen, M.D. (Finland) Juan Ramon d e la Fuente, M.D. (Mexico) Beverley Raphael, M.D. (A us tralia) Robert Reid, M.D. (Canada)
Eric Stromgren, M.D. (Denmark) Peter Sza tmari, M.D. (Canada) George Szmukler, M.D. (England) Alex Tam opolsky, M.D. (Canada) Chris topher Tennant, M.D. (Aus tralia) Sten Theander, M.D. (Sweden) Pekka Tienari, M.D. (Finland) Svenn Torgensen, M.D. (Norway) Peter Trower, Ph.D. (England) Eldon Tlmks, M.D. (Canada) Peter Tyrer, M.D. (Eng land) T. Bedirhan Ustun, M.D. (Switzerland) Per Vagl um, M .D. (Nonvay) Walter Vandereycken, M.D. (Belgium) Jenny Van Drimmelen-Krabbe, M.D. (Switzerland) J. T. van Mens, M.D. (Netherlands) David Veale, M.R.C .Psych. (England) F. C. Verhulst (Netherlands) Marcia VersianL M.D. (Brazil) Marten W. de Vries, M.D. (Netherland s) Dermot Wa lsh, M.B. (Ireland) Winny Weeda-Mannak, Ph.D. ( 'etherlands) John S. Werry, M.D. (New Zealand) Hans Ulrich \'Vittchen, Ph.D. (Germany) Ramsy Yassa, M.D. (Ca.nada) Derson Young, M.D. (China) Michael Zaud ig, M.D. (Germany) Joseph Zohar, M .D. (Israel) Kenneth J. Zucker, Ph.D. (Canada) Roberto Llanos Zuloaga, M.D. (peru)
DSMIV Co ntributors Focused Field-Trial Coordinator Myriam Kline, M.s. Statistical Consultant Helena Kraemer, Ph .D. Anti social Personality Disorder Field Trial Kenneth Towbin, M.D. John S. Werry, M.D. Disruptive Behavior Disorder Field Trial
921
Project Director
Benjamin Lahey, Ph .D. (also Site Coordinator)
Project Director
Thomas A . Wid iger, Ph.D.
Site Coordinators
Russell Bark1ey, Ph.D. Josep h Biederman, M.D. Barry Garfinkel, M.D. Laurence Greenhill , M.D. George Hynd, Ed. D. Keith McBurnett, Ph.D. Jeffrey Newcorn, M.D. Thomas Ollendick, Ph.D.
Site Coordinators
Arthur Alterman, Ph.D. Remi J. Cadoret, MD. Robert Ha re, Ph .D. Lee Robins, Ph .D. Gl'Orge E. Wood y, M.D. Mary C. Zanarini, Ed .D. Autism ilJld Pervasive Developmental Disorders Field Trial
Project Director
Fred Volkmar, M.D. (also Site Coordinator)
Site Coordillators
Magda Campbell, M.D. B. J. Freeman, Ph. D. Ami Klin, Ph .D. Catherine Lord , Ph.D. E. Rihfo, 1 1.0. ... Sir Michael Ru tter, M.D. Eric 5chopler, Ph.D.
Datn Coordillntor
Dorcas Perez, B.A. Major Depression, Dysthymia, and Minor Depressive Disorder Field Trial
Project Director
Martin B. Keller, M.D. (also Site Coordinator)
Project Co-Directors
11ichael B. First, M. D. James Kocsis, M.D. (also Site Coordina tor)
Site Coordillators
Robert M. A. Hirsch fel d, M.D. Charles Holzer, Ph.D. Gabor Keitner, M.D. Daniel Klein, Ph.D. Deborah Marin, M.D. James P. McCu llough, Ph.D. Ivan Miller, Ph.D. Tracie Shea, Ph.D.
Appendix J
Data Coordillators
Diane Hanks, M.A. Cordelia Russell, B.A. Mixed Anxiety-Depressive Disorder Field Trial
Project Directors
Da vid H. Barlow, Ph.D. (also Site Coordinator) Michael R. Liebowitz, M.D. (also Site Coordinator) Richard Zinbarg, Ph.D. (a lso Site Coordinator)
Data Allalysts
Tim Chapman, M. Phil. Salvatore Mannuzza, Ph.D.
Data Coordillator
Hilary Rassnick, M.A. Posttraumatic Stress Disorder Field T rial
Site Coordinators
Phil Brantley, Ph.D. Eugene Broadhead, M.D., Ph.D. Wayne Katon, M.D. Jean-Pierre Lepine, M .D. Jeffrey c. Richards, Ph.D. Peter Roy-Byrne, M.D. Linda Street, Ph .D. Mard jan Teherani, Ph.D. Obsessive-Compulsive Disorder Field Trial
Project Director
Dean Kilpatrick, Ph.D. (also Site Coordinator) Bessel van der Kolk, M.D. (also Site Coordin ator)
Site Coordillators
John Freedy, Ph.D. Sandra Kaplan, M .D. David Pelcovitz, Ph.D. Patricia A. Resick, Ph.D. Heidi Resnick, Ph.D. Susan Roth, Ph.D. Sc.hizophrenia and Related Psychotic Disorders Field Trial
Project Director
Edna Foa, Ph.D. (also Site Coordinator)
Site Coordillators
Jane Eisen, M.D. Wayne Goodman, M.D. Hella Hiss, Ph.D. Eric Hollander, M.D. Michael Jemke, M.D. Michael J. Kozak, Ph.D. Steven Rasmussen, M.D. Joseph Ricciardi, Ph.D. Peggy Richter, M.D. Barbara Rothbaum, Ph.D. Panic Disorder Fie ld Trial
Project Directors
Nancy Com'er Andreasen, M.D., Ph.D. (also Site Coordinator) l'vlichael A. Flaum, M .D. (also Site Coordinator)
Site Coordillators
Xavier Amador, Ph.D. H. Stefan Bracha, M. D. William Edell, Ph.D. Jack Gorman, M.D. Kenneth S. Kendler, M.D. Jeffrey Lieberman, M .D. Thomas McGlashan, M. D. Ananlia K. Pandurangi, M.D. Delbert Robinson, M.D.
Project Director
Abby Fyer, M.D. (also Site Coordinator)
Project Co-Director
James C. Ballenger, M.D. (also Si te Coordinator)
DSM IV Contributors Alfonso Ontiveros, M.D., M.5c. Mauricio Tohen, M.D. Sleep Disorders Fie ld Trial
923 1
Site Coordillntors
Samuel 8. Guze, M.D. Roger Kathol, M. D. Ronald L Martin, M.D. Richard Smith, M.D. James J. Strain, M.D. Sean Yu tzy, M.D. Substan ce Use Field Trial
Project Directors
Daniel Buysse, M.D. (also Si te Coordinator) David J. Kupfer, M.D. Charles F. Reynolds 111, M.D.
Site Coordillntors
Edward Bixler, M.D. Peter Hauri, Ph .D. Anthony Kales, M.D. Rocco Manfredi, M.D. Thomas Roth, Ph.D. Edward Stepanski, Ph.D. Michael Thorpy, M.D.
Project Directors
Linda Cottier, Ph.D. (also Site Coordinator) John E. Helzer, MD. Marc Alan Schuckit, M.D. (also Site Coordinator)
Site Coordillntors
Thomas Crowley, M.D. John R. Hughes, M.D. George E. Woody, M.D.
Dntn Coordillntor
Debbie Mesiano, B.S. Somatization Disorder Field Trial
Project Director
C. Robert Cloninger, M.D.
Appendix J
Jill Mattia, M.A. Eryn Oberlander, M.D. Susan Orsillo, M.A. Peter Roy-Byrne, MD. Paul Salkovskis, PhD. Franklin Schneier, M.D. Samuel M. Turner, PhD. Myrna M. Weissman, PhD. Susan 1. Wolk, M.D. Roberto Zarate, M.A. Delirium, Dementia, and Amnestic and Other Cognitive Disorders Michael O. Colvin, M.D. Marshall Folstein, M.D. Gary Lloyd Gottlieb, M.D. Dilip V. Jeste, MD. Sue Levkoff, D.Se. Benjamin Liptzin, M.D. George W. Rebok, Ph.D. David Salmon, Ph.D. Leon ThaI, M.D. Disorders Usually First Diagnosed During Infancy, Childhood, or Ad olesce nce Brooks Applegate, PhD. Gera ld August, Ph.D. Susan J. Bradley, MD. Joel Bregman, M.D. Patricia Cohen, Ph.D. Michael Flory, Ph.D. Susan Folstein, M.D. Eric Fombonne, MD. Barry Garfinkel, M.D. Richard Green, MD., J.D. Stephanie M. Green, M.s. Jane E. Hood, M.A. Kate Keenan, M.s. Benjamin Lahey, PhD. Marion Leboyer, M.D. Rolf Loeber, Ph.D. Catherine Lord, Ph.D. John McLennan, M.D. T aney Minshew, M.D. Rhea Paul, PhD. Andrew Pickles, Ph.D. Howard M. Rebach, PhD. Mary F. Russo, Ph.D. Sir Michael Rutter, MD. Eric Schopler, Ph.D. Christopher Thomas, M.D. Fred Volkmar, M.D. Katheri ne Williams, Ph.D. Kenneth J. Zucker, Ph.D. Eating Disorders Arnold Anderson, M.D. Christopher Fairburn, MD. Martine Flament, M.D. Paul Garfinkel, M.D. Dean Kilpatrick, Ph .D. James Mitchell, M.D. G. Terence Wilson, Ph.D. Steven Wand erlich, MD. Mood Disorders Gregory Asnis, M.D. Mark S. Bauer, M.D. Diane Bynum Joseph Calabrese, M.D. William CoryeU, M.D. Dav id Dunner, M.D. Ellen Frank, Ph.D. Laszlo Gyulai, M.D. Martin B. Keller, M.D. James Kocsis, M.D. Philip L.wori, Ph.D. Yves LeC rubier, M.D. Robert M. Post, M.D. Samuel J. Simmens, Ph. D. Stuart Sotsky, MD. Dan L Tweed, Ph.D. Lindsey Tweed , M.D. Peter C. Whybrow, M.D. Sharon Younkin Personality Disorders Emil F. Coccaro, M.D. Mark Davies, MD. NUchael B. First, M.D. Rohert Hare, Ph.D. Theodore Millon, Ph D . Vivian Mitropoulou, M.A. Leslie Morey, Ph.D.
DSM-IV Contr ibutors Bruce Pfohl, M.D. Lee Robins, Ph .D. Larry J. Siever, M.D. Jeremy M. Silverman, Ph .D. Andrew Edward Skodol II, M .D . Timothy Trull, Ph .D. TIlomas A. Widiger, Ph.D . Mary C. Zanarini, Ed.D . Pre mens trual D ysphoric Disorder Ellen Frank, Ph .D. Ellen W. Freeman, Ph.D. Lesl.ie Gise, M .D. Judith H . Gold, M.D . Barbara Par ry, M.D. Pallia Schnurr, Ph.D. Sally Severino, M.D. John Steege, M. D. Meir Steiner, M .D., Ph .D. Psychiatri c Systems I nterface Disorders (Adjus tment, Dissociative, Factitious, Impulse-Con trol, and Somatoform Disorders and Psychological Factors Affecting Medical Condition) Henry R. Lesiem, M.D. Juan Enrique Mezzich, M.D., Ph .D. Jeffrey N e w com, M. D. David Spiegel, M.D. James J. Strain, M.D.
925 1
Schizophrenia and Other Psychotic Disorders N an cy Coover Andreasen, M.D., Ph .D. Gretchen H aas, Ph.D. Jeffrey Lieberman, M.D. Patrick McGorry, M .B.B.5. Keith leuchterlein, Ph .D. Mauricio Tohen, M.D. Sleep Disorders Daniel Buysse, M .D. Charles F. Reynold s Ill, M.D. Substa n ce-Related Disorders Jolm Cacciola , Ph .D . Linda B. Cottie r, Ph.D. John E. Helzer, M .D. Rumi Price, Ph.D. Lee Robin s, Ph.D. Marc Alan Schuckit, M .D. George E. Wood y, M. D.
926
Jack E. Downhill, Jr., M.D. Katherine P. Duffy, M.D. Jean Endicott, Ph.D. Michael A. Fauman, M.D., Ph.D. Miriam Gibbon, M.s.W. Jack Gorman, M.D. Paul E. Hagslen, M.D. Michael L Jeffries, M.D. Douglas Langbelm, M.D. Joseph Liberlo, M.D. Da vid B. Mallot, M.D. Del D. Mil ler, Pha rm.D., M.D. Lewis A. Opler, M.D., Ph.D.
Appendix J
Project Coordinator Jennifer Norbeck, M.5.W. Video Consultant Vincent Ciay ton, M.A.
Expert-Phase Participants
The following represents the project participants at the time that DSM-IV went to press. It is anticipated that other sites and individuals w ill join the project.
Jonathan Alpert, M.D. Katherine Attala, r"f.D . Da vid Avery, M.D. Monica Ramirez Basco, PhD. Mark S. Bauer, M.D. (also Site Coordinator) Thomas F. Betzler, M.D. Melanie M . Biggs, Ph.D. (also Site Coordinator) Robert J. Bishop, M.D. Danielle Bordeau, M.D. Malcolm B. Bowers, Jr., MD. Gary Bruss, Ph.D. Peter Buckley, r-,f.D . Deborah S. Cowley, MD. Brian Cox, PhD. James David, MD. Collelte De Marneffe, Ph.D. Judith Dogin, M .D. Sed a Ebrahimi, Ph.D. Jane Eisen, M.D. Maurizio Fava, M.D. Paul Federoff, M.D. Mark K. Fulton, MD. Diego Garcia-Borreguero, M.D. Roya Ghadimi, MD. David S. Goldbloom, M.D. Reed D. Goldstein, Ph.D. (al so Site Coordinator) l'vlicael Golinkoff, Ph.D. Peter Goyer, MD. Alan M. Gruenberg, M.D. Michael E. Henry, M.D. Selby C. Jacobs, M.D. I. Joel Jeffries, M .8. (also Site Coordinator) Sheri Johnson, Ph.D. Kathleen Kim , MD. , M.P.H. Carolyn M. Mazure, Ph.D. (a lso Site Coordinator) Joseph P. McEvoy, M.D. Arnold Merrimam, MD. Timothy L Mueller, M .D. Andrew J ierenberg, M D . Michael Otto, Ph.D. Michelle Pato, MD. Joel Pava, PhD. Katharine Anne Phillips, MD. (also Site Coordinator) Mark Pollack, MD. Hora tio Preva l, M.D. David W. Preven, M.D. (also Site Coordinator) Richard Ries, M.D. Robert C. Risinger, M.D. Robe rt Ronis, M.D. Jerrold F. Rosenbaum, M.D. (also Site Coordinator)
OSM-IV Co ntributors Peter Roy-Byrne, M .D. (also Site Coord inator) Mark Schmidt, M.D. (a lso Si te Coordinator) S. Charles Schulz, M.D. Bmce Schwartz, MD. Michael Schwartz, M.D. (also Site Coordinator) Michael] . Sernyak, M.D. Ri chard Swinson, M.D. Madhukar H. Tri vedi, M. D. Andrea Weiss, MD. Kerrin White, M.D. Lawrence Wil son, M. D. John V ,Iorthington, M D. Joan Youchah, M.D.
927
Appendix K
Other Cognitive Disorders, and Mental Disorders Due to a General Medical Condition Text Revision Work Group
William Breilbart, M.D. Martin Cole, M.D. Benjamin Uptzin, M.D. Jacobo E. Mintzer, M.D. Michael K. Popkin, M.D. Peter V. Rabins, M.D. Gary W. Small, M.D. Friedrich Stiefel, M.D. Gary J. Tucker, M.D.
929
930
Gary Mesibov, Ph.D. N ancy Mins hew, M.D. Sally Ozonoff, Ph.D. Rhea Paul, Ph .D. John Piacentini, Ph.D. John Pomeroy, M.D. Byron Rourke, F.R.5.C. Sir Michael Rutter, M.D.
Appendix K
John E. Schowalter, M.D. Larry Silver, M.D. Ludwik Szymanski, M.D. Digby T antam, F.R.C.Psych. Lorna Wing, M.D. Sula Wolff, F.R.CP.
'<\'.
931
Elsa Ronn ingstam, Ph.D. Megan Rutherford, Ph.D. Larry }. Siever, M.D. Robert L. Spitzer, M.D. Timothy Trull, Ph.D. Peter Tyree, M.D.
Gerald Nestad t, M.D. John Oldham, M.D. Joel Paris, M.D. Katharine A. Phillips, M.D. P,ml Pilko nis, Ph.D. James Reich, M.D., M .P.H. Lee Robins, Ph.D.
Ap pend ix David Veale, M.D. Matti Virkkunen, M.D. , Ph .D. Thomas N. Wise, M.D.
Advisers to Schizophrenia and Other Psychotic Disorders Text Revision Work Group
Nancy Andreasen, M.D., Ph.D. David Braff, M.D. Michaeline Bresnahan, Ph .D. Jill M. Goldstein, Ph .D. Michael G reen, Ph.D. John Hsiao, M.D. Richard Keefe, Ph.D. Dolores Malaspina, M.D., M.5.P.H. Thomas McG lashan, M.D. Henry asraUah, M.D. Jud ith Rapoport, M.D. Marc-Andre Roy, M .D., i\<I.Sc. Ezra Su sser, M.D.
Index
Pagt.' 11 lImbers for diagnostic ,riUria or resl!arcll criteria an-' ellclosed ill parelltllf'ses.
Akathisia, acu te Neuroleptic-i nduced, 735, 800 (802) Alcohol-induced disorders Intoxication, 21.,l (215) Other disorders, 217 Withdrawal, 215 (216) Alcohol-related disorders, 212 Not otherwise specified, 223 Alcohol use disorders Abuse, 214 Dependence, 213 Alzheimer's type dementia, 15-l (157) Amnesia. See Amnestic disorders; Dissociative amnesia Amnestic disorders Due to a general medical condition, 175
(177) Not otherwise spedfied, 179 Subst.mce-induced persisting amnestic disorder, 177(1i9) Amphetamine-induced disorders Intoxication, 226 (227) Other disorders, 228 Withdra\\'al, 22.7 (228) Amphetamine (or amphetamine-like}related disorders, 223 Not othem'Lse specified, 231 Amphetamine use disorders
Abuse of substances, 198 (199) See (1/50 SI't'cijic slIbslallUS by lin/lit' Abuse or neglect problems. 738 Neglect of child, 738 Physical ahuse of adult, 738 Physical abuse of child, 738 Sexual abuse of adult, 738 Sexual abuse of child, 738 Academic problem, 741
Abuse, 275 Dependence, 224 Anorexia nen'osa, 583 (589) Antisocial behmi or Adult, 7"\0 Child o r adolescent, 7.,\0 Antisocial personality disorder, 701 (706) Anxiety disorders, -l19 Acute stress disorder, 469 (.,l71) Agoraphobia, 432 (433) Panic disorder with, .,l33 (441 ) Without history of panic disorder, 441 (443)
933
1 934
Anxiety disorders (cv11tinlled) Due to a general medical condition, -176 (.79) Generalized anxiety disorder (includes o \'c r,lI\XiOU5 disorder of childhood),
472 (476)
Index
B
Bereavement 7-10 Binge-eating d isord e r, 785 (787) Bipolar disorders Bipolar I diso rder M ost recent episode depressed, 382 (39 1) M ost recent episode hypomanic, 382 (388) h'!ost recent episode manic, 382 (389) M ost recent episode mixed, 382 (390) Most recent episode unspecified, 382 (392) Single manic episode, 382 (388) Bipolar II d isorde r (recurrent major depressin! episodes with hypomanic episodes), 392 (397) C yclot hy mic disorder, 398 (400) Not otherwise specified, 400 Body dys morphic disorder, 507 (510) Borderline inteUectual functioning. 740 Borderline personality disorder, 706 (710) Bre,l thing-related sleep disorder, 6 15 (622) Brief psychotic disorder, 329 (332) Bulimia ne rvosa, 589 (594)
Panic a ttack, 430 (-132) Panic d isorder, 433 (440-44 1) With ago raphobia, 433 (441)
Specific phobi.l -l. B (449) Substance-indu ced .1n.xiety disorder, 479 (483) Anxiolytic-relatcd disorders. See Sedative-, hypnotic-, or anxiolytic-re lated
disorders
Arousal disorders. See Sexual a rousal disorders Asperger's d isorder, 80 (84) Attenlion-dcficit and disruptive behavior disorders, 85 At tcnHan-defiell/hyperac!i vii}' diso rder, 85 (92) Combined ty pe, 87 (93) Predominantly hyperactke-irnpulsin' type, 87 (93) Predominantly inattentive type, 87 (93) A ttention-deficit/hyperacti v ity diso rder not othenvise specified , 93 Conduct disorder, 93 (98) Disruptive behavior d isord er not o them' ise specified, 103 Oppositional defiant disorder, 100 (102) Atten tion-defici t/ hyperactivity disorder, 85 (92) Not othem'ise specified, 93 Atypical autism, S..J, Aty p ical features specifier for mood episode, 420 (422) Autistic disorder, 70 (75) Amidant personality d isorder, 718 (721)
c
Caffeine-induced d isord ers Intoxication, 232 (232) Other disorders, 233 Caffeine-rela ted disorders, 231 Not o therwise specified, 234 Caffeine Withdrawal, 764 (765) Cumabis-induced disorders Intoxication, 237 (238) Othe r dis o rde rs, 238 Cannabis- related disorders, 23.4 Not othem'ise specified, 241 Cannabis use d isorders Abuse, 236 Dependence, 236 Catatonic disorder Due to a general medical condition, 185 (187) Catatonic features specifie r for mood episode, 417 (41 8) Catatonic type of schizophrenia, 315 (3 16) Child antisocial behavior, 740 Childhood disin leg rati\c disorder, 77 (79) Child o r adolescent antisocial behaVior, 740
Index
Chronic motor or vocal tic disorder, 114 (115) Chronic specifier for major depressh'e episode, -117 (41 7) Circadian rhy thm sleep disorder, 622 (629) Cocaine-induced disorders Intoxica tion, 2-1-1 (245) Other disorders, 246 Withdrawal, 2-15 (2-16) Cocaine-related disorders, 2B Not otherwise specified , 250 Cocaine use disorders Abuse, 2-B Dependence, 2-12 Cogniti\-e disorders See also Amnestic disorders; De lir ium; Dementia Age-related cognitiw decline, 7-10 Not otherwise s pecified, 179 Communication disorders, 58 Expressive langu.1ge disorde r, 58 (61 ) Mixed receptive-expressiw la nguage disorder, 62 (6-1) Not otherwise s pecified. 69 Phonological disorder, 65 (66) Stuttering, 67 (69) Conduct disorder, 93 (98) Com-ersion disorder, -192 (-198) Creunfeldt-Jakob disease Dementia due to, 166 (168) Culrnre-bound s yndromes, 897-903 Cyclothymic disorder, 398 (-100)
935 1
Dementia, 147 of the Alzheimer's type, 154 (157) Due to multiple etiologies, 170 (171 ) Due to other general medical conditions, 162, 167 (168) Creunfeldt-Jakob disease, 166 (1 68) Head tr,1Oma, 164 (168) HIV d is ease, 163 (168) H unting ton's disease, 165 (168) Parkinson's disease, 16-1 (168) Pick's disease, 165 (168) Not otherw ise specified, 171 Substance-induced persisting dementia, 168 (170) Vascular, 158 (161) Dependence on s u bstances, 192 (197) Set' also sflrcific sub5lanus by lIamr Dependent personality disorder, nl (725) Depersonalization diso rd er, 530 (532) Depressin! disorders Dysthymic diso rder, 376 (380) Major dep reSSive disorder, 369 Recurrent, 369 (376) Single episode, 369 (375) Not othem' ise specified, 3S1 Depressive episode, major, 349 (356) Depressive personality disorder, 788 (789) Develo pmental articula tion diso rde r.. 51!/? Phonological disorder Developmental coordination disorder, 56 (58) Developmental disorders. Sel! Learning disorders; Mental retardation; Penras i\e developmental disorders Diagnosis deferred on Axis ll, 743 Diagnosis or condition deferred on Axis I,
o
Defensive Functionin g Scale, 807-813 Delirium, 136 Due to a general medical conditio n, 1-11 (1-13) Due to multiple etiologies, 146 (1-17) Not otherwise specified, 147 Substance-ind uced, 143 (1-15-146) Delirium, dementia, and amnestic and other cognitive disorders, 135 Amnestic disorders, 172 Cogniti ve disorder not otherwise s pecified , 179 Delirium, 136 Dementia, 147 Delusional disorde r, 323 (329)
m
Disorder of infancy, childhood, or adolescence not otherwise s pecified, 13-1 Disorder of written expression, 54 (56) Disorders usually first diagno sed in infanc)" childhood, o r a dolescence, 39 Attention-deficit and dis ruptive behavior disorders, 85 Co nununication disorders, 58 Disord er of infancy, childhood, or adolescence not otherwise specified,
134
Elimination disorders, 116 Feeding and eating d isorders of infancy or ear ly childhood, 103 Learning diso rd ers, 49
936
Disorders usually first diagnosed in infancy. childhood. or adolescence (amti1HIf'd) Ment"l retardation, 41 Motor skills disorder, 56 Pervasive developmental disorders, 69 Reactive attachment disorde r of infanc),
or early chi ldhood, 127 (130) Selective mutism, 115 (127)
Ind ex
Bulimia nervosa, 589 (59-1) Not othem'ise specified, 594 Elective mutism. See Selective mutism Elimina tion disorders. See Encopresis; Enuresis Encopresis With constipation and O\'erflow incontinence, 11 6 (118) Without constipation and overflow incontinence, 116 (l18) Enuresis (not due to a general medical condi ti on), 118 (121) Erectile disorder, male, 545 (547) Du e to a general medical condition. 558 (561) Exhibitionis m , 569 (569) Expressive language d iso rder, 58 (61)
F
Tic disorders, 108 Disorganized type of schizophrenia, 314 (315) Disruptive behavior disorders. See Attention-deficit and disrupth-c behavior disorders
Dissociati ve amnesia, 520 (523)
E
Eating disorders, 583 See also Feeding and eating disorders of infancy or early childhood Anorexia nenosa, 583 (589)
Fa ctitious disorder by p roxy, 781 (783) Factitious disorders, 513 No t othem' ise specified, 517 With combined psychological and phys ical signs and symptoms, 515 (517) ,",lith predominantly physica l s igns and symptoms, 514 (517) With predominantly psychological signs and symptoms, 5H (517) Feeding and eating disorders of infancy or early childhood, 103 Feeding disorder of infancy or early childhood, 107 (108) Pica , 103 (105) Rumination disorder, 105 (106) Feeding disorder of inf,1ncy or early ch ildhood, 107 (108) f emale orgasmic disorder, 5-l7 (5-'9) Female sexual arousal disor der, 5-'3, (544) Fe tishism, 569 (570) Tra nsvestic, 574 (575) Flashbacks. See H a ll UCinogen p ersisting perception disorder (flashba cks) Folie deux. See Shared psychotic disorder Frotteurism, 570 (570) Fugue. See Dissociative fugue
Index
Gambling. Sf'/! Pathological gambling GARF Scale. See Global Assessment of Relational Functioning Scale Gender identity disorder, 576 (SS I) in adolescents or aduils (58t) in children (581) Not otherwise specified, 582 General medical condition Amnestic disorder due 10, 175 (177) Anxiety disorder due to, 476 (479) Catatonic diso rder due to, 185 (187) Delirium due to, 141 (143) Dementia due to, 15+-168 Mental disorder due to, 181 Mental disorder not otherwise specified due to, 190 Mood disorde r due to, 401 (40-1) Pain disorder associated with, 498 (503) Personality change due to, 187 (190) Psychotic disorder due to, 33-1 (338) Relational problem related to, 737 Sexual dysfunction due to, 558 (56 1) Sleep disorder due to, 651 (654) Generalized anxiety disorder (includes overanxious disorder of childhood),-I72 (476) Global Assessment of Functioning (GAF) Scale, ].I Global Assessment of Relational Functioning (GARF) Scale, 814-816
H
937
Hypersomnia Prinlary,604 (609) Rela ted to another mental disorder, 6+5 (650) Substance-induced, 655 (660) H ypnotic-related disorders. See Scdath'e-, hypnotic-, or anxiolytic-related disorders Hypoactive sexual desire disorder, 539 (5-11) Due to a general medical condition. 558
(;61 )
Hallucinogen-induced disorders Hallucinogen persisting perception diso rder (flashbacks), 253 (25,1) Intoxication, 252 (253) Other disorders, 254 Hallucinogen-related disorders, 250 Not othenvise specified, 256 Hallucinogen use disorders Ab use, 252 Dependence, 251 Head tr.luma Dementia due to, 164 (168) Histrionic personality disorder, 71 1 (714) HIV disease Dementia due to, 163 (168) Hu ntington's d isease Dementia due to, 165 (168) Hyperactivity. See Attention-<ieficit/ hyperactivity disorder
Identity disorders. See Dissociative disorder; Ge nder identi ty disorder Identity problem, 741 Impulse-control disorders not elsewhere classified, 663 Intermittent explosi\'e disorder, 663 (667) Kleptomania, 667 (669) Not othen vise specified , 677 Pathological gambling, 671 (67-1) Pyromania, 669 (671) Trichotillomania, 674 (677) Inhalant-induced disorders Intoxication, 259 (260) Other disorders, 260 Inhalant-related disorders, 257 Not othe m 'ise specified, 263 Inhalant use disorders Abuse,259 Dependence, 258 Inhibited female orgasm. See Female orgasmic disorder Inhibi ted male orgasm. See t-,'I.l le orgasmic disorder Insomnia Primary, 599 (60-1) Related to another mental disorder, 645 (650) Substance-induced, 655 (660) Intellectual functioning. Su Borderline intellectual functioning Intermittent explosive disorder, 663 (667) Intoxication, 199 (20 1)
938
L
Leaming diso rders Disorder of written expression, 54,
(56)
In dex
Mental retarda tion , 4 1 (49) Mild, 43 (49) Moderate, 43 (49) Profound, +I (49) Severe, 4 3 (49) Sc\'erity unspecified, 44 (49) r le ntal re ta rd ation, severity unspecified, 44 ...
(49)
Mathematics disorder, 53 (54) Not otherwise specified. 56 Readi ng disorde r, 51 (53) longitudinal course specifiers (with and without full interepisode recovery) fo r mood disorders. 424 (.125)
M
Mild mental retardation, 43 (49) ~'Iild neurocognitive disorder, 762 (764) Minor depressive disorder, n5 (777) M ixed anxie ty-depressive disorder, 780
(7BI)
~'Ia le
Mathematics disorder, 53 (54) t-,Ied.ication-induccd d isorder Adverse effects of medication not otherwise specified, 736 Medication-induced movement disorders, 734,791
Neurolepticinduced acute akathisia, 735,
800(802)
Neuroleptic-induced acu te dystonia, 735, 798 (BOO) Neu roleptic-induced parkinsonism, 735, 792 (795) Neu roleptic-induced tardive d yski n esia, 736, 803 (805) N euroleptic malignant syndrome, 735, 795 (798) N o t othen"ise specified, 736, 807 Postu ral tremor, 736, 805 (807) Melancholic features specifier for mood episode, 419 (420) Mental disorder not othcm'ise specified due to a general medical condition,
190
Mood d isorders, specifiers for, 410 Atypical features specifier, -120 (422) Catatonic featu res specifier, 417 (418) Chronic specifie r, 41 7 (417) Longitudinal course specifiers (with and without fun interepisode recovery). 424 (425) Melancholic features specifier, 419 (420) Postpartum o nset s pecifier, 422 (423) Rapid-cycling specifier, 427 (428) Seasonal pattern specifier. 425 (427) Severi Iy / psychoti c/ remiss ion specifiers Major dep ressive episode, 411 (413) Manic episode. 413 (415) Mixed episode, 415 (416) Mood episodes H ypo m an ic episode, 365 (368) Major d epressive episode, 3-19 (356) Manic episode, 357 (362) ~'I ixed episode, 362 (365) Motor or vocal tic disorder, chronic. See Chronic motor or vocal tic diso rd er
Index
too'lotor s kills disorder, 56 Developmental coordination disorder, 56 (58) Multi-infarct dementia. See Vascular demen tia Mul tiple etiologies Delirium due to, 146 Dementia due to, 170 (171) Multiple personality disorder. Sre Dissociatiw identity disorder Oisrupth'e behavior disorder, 103 D issociati ve disorder, 532 Dyssonmia, 629 Ea ting disorder, 59-1 Factitious disorder, 317 Gender identity disorder, 582 H allucinogen- re la ted disorder, 256 Impulsc-control disorder, 677 Inhalant-related d isorder, 263 Learning d iso rd e r, 56 Medication-induced move ment disorder,
(1m
Narcissistic personality disorder, 714 (717) Narcolepsy. 609 (615) Neglect of child, 738 Neuroleptic-induced disorders Acute akatltisia, 735, 800 (802) Acute d ystonia, 735, 798 (800) Neurolep tic malignant syndrome, 735, 795 (798) Parkinsonism, 735, 792 (795) Tardive dyskinesia , 736, 803 (805) Neuroleptic malignant syndrome, 735, 795 (798) Nico tine-induced disorder Withdrawal, 265 (266) Nicotine-related disorders, 26-1 Not otherwise spcciIied, 269 Nicotine u se disorder Depe ndence, 26-1 Nightmare disorde r, 631 (63.J) No diag nos is on Ax is U, 743 No di agnOSiS or condition on Axis I, 7,13 Noncompliance with treahnent, 739 Not othen\'ise specified Adverse effects of medication, 736 Alcohol-related disorder, 223 Amnestic disorder, 179 Amp hetamine-related disorder, 231 Anxiety disorder, -I8-I Attention-rlefidt / hyperacti, ity disorder, 93 Bipolar disorder,-IOO Caffeine-related disorder, 23-1 Cannabis-related disord e r, 241 Cocaine-related disord er, 250 COb 'TIitil'e disorder, 179 Communication d iso rd er, 69 Delirium. 147 Dementia, 171 Deprcssh'e disorder, 38 1 Disord e r of infancy, ch ildhood, or "dolescence, l3-1
736,807
t.lental d isord er due to a gene ra l medical condition, 190 M ood d isorder, no Nicotine-related d iso rder, 269 Opioid-related disorder, 277 Other (o r unkno\\' n ) su bstance-related disorder, 295 Pa raphilia, 576 P.1Tasomnia,6-14 Persona lity disord e r, 729 Pervasive developmental disorde r (including a t}'pical autism), ~ Phencyclidine (o r phencyclidi ne-like)related disorders, 2&3 Psychotic disorder, 3-13 Relationa.l problem, 737 Sedative-, h ypnotic, o r anxiolytic-rclated disorder, 293 Sexual disorder, 582 Sexual dysfunction, 565 Som a to fo rm disorder, 511 Tic disorder, 11 6
o
Obsessive-compulsive disorder, 456 (462) O bsessivc-compulsive personality disorder, 723 (729) Occupational prob lem, 7-11 O p ioid-induced d isorders Intoxic.ltion, 271 (272) Other disorders, 274 \-Vithdrawa l, 272 (273) Opioid-related d isorders, 269 No t othem' ise speci fied, 277 Opioid use d iso rd ers Abuse, 271 Dependence, 270 Oppositional defiant d iso rder, 100 (102)
Index
Orgasmic disorders Female orgasmic disorder, 547 (549) Male orgas mic disorder, 550 (552) Premature ejaculation, 552 (554) Overanxious disorde r of childhood. See Gene ralized anxie ty disorder
p
Pain disorder See a/so Sexual pain disorders Associated with a general medical condition, 498 (503) Associated with both psychological factors and a general medical condition, 498 Associated with psycholOgical factors, 498 Panic attack, 430 (432) Panic disorder, 433 (440-441) With agoraphobia, 433 (440-441) Without agoraphobia, 433 (440-441) Paranoid personality disorde r, 690 (694) Paranoid type of schizophrenia, 313 (314) Paraphilias, 566 Exhibitionism, 569 (569) Fetishism, 569 (570) Fro tteurism, 570 (570) Not othem'ise specified, 576 Pedophilia,571 (572) Sexual masochism, 572 (573) Sexual sadism, 573 (574) Transvestic fetishism, 574 (575) Voyeurism, 575 (575) Parasomnias,630 Nightmare disorde r, 631 (634) Not othem'ise specified, &l4 Sleep terror disorder, 634 (639) Sleepwalking disorder, 639 (644) Parentchild relational problem, 737 Parkinsonism Neurolepticinduced, 735, 792 (795) Parkinson's disease Dementia due to, 164 (168) Partner relational problem, 737 Passive-aggressive personality disorder (negativistic personality diso rder), 789 (791) Pathological gambling, 671 (674) Pedophilia,57l (572) Personality change due to a general medical condition, 187 (190)
Personality d isorders, 685 (689) Antisocial personality disorder, 701 (706) Avoidant personality d isorder, 718 (721) Borderline personality disorder, 706 (710) Dependent personality disorder, 721 (725) His trionic personality disorder, 711 (714) Narcissistic personality disorder, 714 (717) No t othenvise specified, 729 Obsessivc-<ompulsive personality disorder, 725 (729) Pa ranoid personality disorde r, 690 (694) Schizoid personality disorder, 694 (697) Schizotypal personality d isorder, 697 (701) Pervasive developmental disorder not otherwise specified, 84 Pervasive developmental diso rders, 69 Aspergec's diso rder, 80 (84) Autistic d isorde r, 70 (75) Childhood disintegrative disorde r, (79) Not othenvise specified (including atypical autism), 84 Re tt's d isorder, 76 (77) Phase of life problem, 742 Phencyclidine-induced disorders intoxication, 280 (281) Other disorders, 281 Phencyclidine (or phencydidine--like)-related disorders, 278 Not othem'ise specified, 283 Phencyclidine use diso rders Abuse, 279 Dependence, 279 Phonologica l d isorder, 65 (66) Physical abuse of adult, 738 of child, 738 Pica, \03 (105) Pick's disease Dementia due to, 165 (168) Polysubstance-related disorder Polysubstance dependence, 293 Postconcussiona l disorder, 760 (761 ) Postpartum onset specifier for mood episode, 422 (423) Postpsychotic depressive disorder of sdtizophrenia, 767 (768) Posttraumatic stress disorder, 463 (46n Postural tremo r, medication-induced, 736, 805 (SOn
Index
Premature ejaculation, 552 (55-1) Premenstrual dysphoric disorder, 771 (774) Primary hypersomnia, 604 (609) Primary insomnia, S99 (604) Primary s leep disorders Dyssomnias, 598 Parasomnias,63O Profound mental retardation, 44 (49) Psychogenic amnesia _See O issociati\"e amnesia Psychogenic fugue_ St'l! Dissociative fugue Psychological factor a ff&ting medical condition, 73 1 (73-1) Psychotic d isorders Brief p sychotic disorder , 329 (332) Delusional disorder, 323 (329) Due to a gene ral medical condition, 334 (338) Not otherwise specified, 3-13 Schizoaffedive disorder, 319 (323) Schizophrenia, 298 (3 12) Schizophreniform disord er, 317 (319) Shared psychotic disorder, 332 (334) Substance-induced psychotic disorde r, 338 (3<2) Psychotic features specifier Majo r d epress ive episode, 411 (413) Manic e pisode, 413 (415) /I.'lli:ed episode, 415 (416) Pyromania, 669 (67 1)
R
5
Schizoaffective disorder, 319 (323) Schizoid personality disorder, 694 (697) Schizophrenia, 298 (312) Altemath-e dimensional descriptors, 765 (766) Catatonic type, 315 (3 16) Disorganized type, 314 (315) P.1Tanoid type, 313 (314) I~esidualtype, 316 (317) Undifferentiated type, 316 (3 16) Schizophrenia and other psy chotic disorders _See Psychotic disorders; Schizophrenia 5chlzophreniform disorder, 317 (3 19) Schizot}'Pal personality disorder, 697 (701) Seasonal pattern specifier for mood disorder,
i l l (427)
Sedath-e-, h)'Pnotic-, o r arudolytic-induced disorders intoxicatio n , 286 (287) Other disorders, 289 Withdrawal, 287 (289) Sedative-, h ypnotic-, or anxiolytic-rcla ted disorders,28-l Not otherwise specified, 293 Sedative, h}'Pnotic, or a nxiol ytic use diso rders Abuse, 286 Dependence, 285 Sedative-related disorders_ See Sedative- h}'P notic -, or anxiolytic-rclated disorders Selecti\"e mutism , 125 (127) Separation anxiety disorde r, 121 (125) Se\'er e mental retardation, -l3 (49) Se\'erit}' / psychotic / remission specifiers ~'Il aior depressive episode, 411 (413) r.,'lanic episode, 413 (-lIS) Mixed episode, 415 (416) Severit}' lU\Specified mental reta rdation 44 (49) " Sexual abuse of adult, 738 of child, 738 Sexual arous al disorders Female sexual ar ousal disorde r, 543 (5+1) Male erectile disorder, 545 (547) Due to a general n,edical condition, 558 (561) Sexual aversion disorder, 541 (5-12)
Rapid-cycling specifier for mood diso rde r, 427 (428) Reactive attachment disorder of infancy or early childhood, 127 (130) Reading d isorder , 51 (53) Recurrent brief depressive disorder, 778 (779) Relational problems, 736 Not otherwise sp ecified, 737 Parent-child relational p roblem, 737 Partner relational problem, 737 Re lated to a mental disord er or general medical condition, 737 Sibling relational problem, 737 Religious or spiritual problem, 741 Residua l t}'Pe of schizophrenia, 316 (31 7) Rett's disorder, 76 (77) Rumination disorder, 105 (106)
942
Sexual desire disorders Hypoacti\'c sexual desire disorder, 539 (5-1 1) Due to a general medical condition,
538 (561)
Index
Sibling relational problem, 737 Simple deteriorati\'e disorder (simple schizophrenia), 769 (771) Simple phobia. See Specific phobia Sleep disorders, 597 D ue to a gene ra l medical condition, 65 1 (654) H ypersomnia type, 652 (654.) Insomnia type, 652 (654) r-,Iixed type, 652 (654) Parasomnia type, 652 (654) Primary sleep disorders DyssolTU1ias, 598 Pa rasomnias, 630 Related to anothe r menial diso rder Hypersom n ia re lated 10 an o the r mental disord er, 645 (650) Insomnia related to anolher men tal disorder, 645 (650) Substance-induced sleep disorder. 655 (660) Sleep terror d isorder, 634 (639) Sleep-w,lke schedule disorde r. See Circadian rhylhm sleep disorder Sleepwalking disorder. 639 (644) Social an d Occupational Flmctioning Assessment Scale (SOFAS). 817-8 18 Social anxiety d isorder. SeE Social phobia (social anxie ty disorder) Social phobia (social anxiely disorder). 450 ('56) SOFAS. See Social and Occupational Functioning Assessment Scale Somati zation disorder, 486 (490) Somatoform disorders, 485 Body dysmorphic diso rd er, 507 (510) Conversion disord er. 492 (498) H ypocho n drias is. 504 (507) No t otherwise specified. 511 Pain disorder Associated with a generill medical condition, 498 (503) Associated with both psychologic.l ! factors and a general medica! condition, 498 (503) Associated with p sychologic.ll faclors, 498 (503) Soma tiLltion d isord er, 486 (490) Undifferentiated somatoform disorder, 490 (492) Specific pho bia, 4-13 (449)
Sexual.wersion d isorder, 541 (542) Sexual disorders See 11150 Parap hiLias; Sexual dysfwlctions Not othem'ise specified, 582 Sexual dysfunctions. 535 Due to a genecal medical condition, 558
(561)
Not othem'ise sp ecified, 565 Orgasmic disorders Female orgasmic disorder, 547 (5-19) Male orgasmic d isorde r, 550 (552)
Prema tu re ejaculation , 552 (55-1)
Sexual arousal disorders Female sexual arousal disorder, 543 (5-14) ~'I ale erectile diso rder, 545 (5-17) Due to a gener.ll medic,)l condition, 558(561) Sexual desire diso rders Hypoactive sexual d esire d isorder, 539
(541) Due 10 a general medical conclition, 558 (561)
562 (565)
Sexual masochism, 572 (573) Sexual pain disorders Dyspa reunia Due to a general medical condition, 558 (561) Not due to a general medic'l l conditio n, 554 (556) Vaginis mus (n ot due to a gene ra l medical conditi on), 556 (558) Sexual sadism, 573 (574) Shared psychotic disorder , 332 (33-1)
In d e x
Spiritual problem. See Religious or spiritual problem Stereotypic movement disorder, 131 (134) Stereotypy I habit disorder. See Stereotypic ffimement disorder Stress disorder. Sre Acute s tress disorder Stuttering, 67 (69) Substance-induced d isorders, 199
943
Not othen\'ise specified, 116 Tourette'sdisorder, III (114) Transient tic disorder, 11 5 (116) Tourene's disorder, 111 (114) Transient tic disorder, 115 (116) Transvestic fetishism, 574 (575) Tremor. See Postural tremor, medicationinduced T richotiUomania, 674 (677)
u
Undifferentiated soma toform disorder, 490
(492)
Undifferentiated type of schizophrenia, 316 (316) Unspecified mental disorder (non psychotic),
743
v
Vaginismus (nol due to a general medica l condition), 536 (558) V.15Cular d ementi.l , 138 ( 16 1) Vocal tic disorders. See Chronic molor or \ocallic disorder Voyeuris m, 573 (575)
w
Withdrawal from subs ta nces, 201 (202) See also specific substances by name Written expression, d isorder of, 54
(56)
Tardive d yskinesia Neuroleptic-induced, 736, 803 (805) Tic disorders, 108 Chronic motor or vocal tic d isorder, 114
(1 15)